Basic Information
| Provider Information | |||||||||
| NPI: | 1255900254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | RAVEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12546 PROMENADE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482131416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136247712 | ||||||||
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| Practice Location | |||||||||
| Address1: | 28303 DEQUINDRE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486581116 | ||||||||
| FaxNumber: | 2486581120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2021 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.