Provider Demographics
NPI:1053477141
Name:THOMAS, SUZANNE RENSEL (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:RENSEL
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29260 FRANKLIN RD
Mailing Address - Street 2:STE 111
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1196
Mailing Address - Country:US
Mailing Address - Phone:248-356-6460
Mailing Address - Fax:
Practice Address - Street 1:29260 FRANKLIN RD
Practice Address - Street 2:STE 111
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1196
Practice Address - Country:US
Practice Address - Phone:248-356-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010112811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0005013741OtherAETNA PROVIDER NUMBER
MI80-0890917OtherBLUE CROSS BLUE SHILE ID
MI0890917-8-80-1Medicare ID - Type UnspecifiedPROVIDER NUMBER