Basic Information
| Provider Information | |||||||||
| NPI: | 1407165822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THELEN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | GARY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW, CAADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5631 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | LYONS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488519792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168224603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801092492 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.