Basic Information
| Provider Information | |||||||||
| NPI: | 1487287504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MAAS-IRCOD, M.ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003953223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6549 TOWN CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003953223 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2020 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 6451019717 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.