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General NPI Number Information
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NPI Number | 1235594284
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Entity Type | Organization
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Legal Business Name | BETTY J THACK MA PLLC
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Dates
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Enumeration Date | 12/17/2015
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Last Update Date | 01/16/2016
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Provider Practice Location Address
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Address Line | 711 WEST THIRTEEN MILE RD BETTY THACK MA LPC
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City | MADISON HEIGHTS
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State | MI
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Zip | 48071
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Country | US
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Telephone | 248-761-9771
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Fax |
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Provider Business Mailing Address
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Address Line | 711 WEST THIRTEEN MILE RD BETTY THACK MA LPC
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City | MADISON HEIGHTS
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State | MI
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Zip | 48071
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Country | US
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Telephone | 248-761-9771
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Fax |
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Authorized Official
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Title or Position | COUNSELOR/PSYCHOTHERAPIST
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Name | BETTY JANE THACK
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Credential | MA LPC NCC
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Telephone | 248-761-9771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 6401009796
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License Number State | MI
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