Provider Demographics
NPI:1124573258
Name:THAIN, ALAN JACOB
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:JACOB
Last Name:THAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 E HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3350
Mailing Address - Country:US
Mailing Address - Phone:414-336-8997
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR
Practice Address - Street 2:#100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4404
Practice Address - Country:US
Practice Address - Phone:248-613-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016758103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling