=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659422848
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIRDELL F THOMAS LMSW,CCS,CAADC,CPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 02/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1121 EAST MCNICHOLS
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-365-3113
-----------------------------------------------------
Fax | 313-365-3098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5077 AUDUBON RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-2658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-588-0101
-----------------------------------------------------
Fax | 800-286-1782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801060361
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------