Basic Information
| Provider Information | |||||||||
| NPI: | 1790102689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | SELIINA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIPILA | ||||||||
| OtherFirstName: | EMMA | ||||||||
| OtherMiddleName: | SELIINA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 31075 FLORALVIEW DR S APT 207 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483315861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347717236 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6888 W MAPLE RD FL 1 | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488468700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-17-26386 | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.