Basic Information
| Provider Information | |||||||||
| NPI: | 1205120052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLIFF | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12850 FOUNTAIN SQ STE 106 | ||||||||
| Address2: | |||||||||
| City: | DAVISBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483502552 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 26522 VAN DYKE AVE | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867594400 | ||||||||
| FaxNumber: | 5867594401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 06/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801093026 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 750910402 | 01 | MI | BLUE CROSS | OTHER |