Basic Information
Provider Information | |||||||||
NPI: | 1194472902 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SARAH TOMAKICH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2272 E MICHIGAN AVE | ||||||||
Address2: | SUITE 223 | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 48912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2315345432 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2272 E MICHIGAN AVE | ||||||||
Address2: | SUITE 223 | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 48912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2315345432 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2022 | ||||||||
LastUpdateDate: | 03/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALEXANDER | ||||||||
AuthorizedOfficialFirstName: | VALERIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLER | ||||||||
AuthorizedOfficialTelephone: | 6167351505 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.