Healthcare Provider Details

I. General information

NPI: 1467112151
Provider Name (Legal Business Name): LAKEISHATHOMASPLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 PEARL ST STE 307
YPSILANTI MI
48197-2663
US

IV. Provider business mailing address

124 PEARL ST STE 307
YPSILANTI MI
48197-2663
US

V. Phone/Fax

Practice location:
  • Phone: 734-404-8682
  • Fax:
Mailing address:
  • Phone: 734-404-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LAKEISHA THOMAS
Title or Position: CLINICAL DIRECTOR
Credential: LLMSW
Phone: 734-404-8682