=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760978043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS TRAUMATOLOGY INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2018
-----------------------------------------------------
Last Update Date | 07/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11825 DEXTER AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48206-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-312-0087
-----------------------------------------------------
Fax | 313-447-2277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11825 DEXTER AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48206-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-312-0087
-----------------------------------------------------
Fax | 313-447-2277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NAKPANGI THOMAS
-----------------------------------------------------
Credential | MS, LPC, NCC, CT, AC
-----------------------------------------------------
Telephone | 313-312-0087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401012784
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number | 6401012784
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 6401012784
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------