Provider Demographics
NPI:1104200369
Name:THOMAS, SALLIE
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-9100
Mailing Address - Country:US
Mailing Address - Phone:231-884-0786
Mailing Address - Fax:231-468-2215
Practice Address - Street 1:1904 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-9100
Practice Address - Country:US
Practice Address - Phone:231-884-0786
Practice Address - Fax:231-468-2215
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010935881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical