Provider Demographics
NPI:1235324484
Name:THERA SUPPORT
Entity Type:Organization
Organization Name:THERA SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-677-0200
Mailing Address - Street 1:4343 CONCOURSE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-8672
Mailing Address - Country:US
Mailing Address - Phone:734-677-0200
Mailing Address - Fax:734-677-3310
Practice Address - Street 1:4343 CONCOURSE DR STE 250
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-8672
Practice Address - Country:US
Practice Address - Phone:734-677-0200
Practice Address - Fax:734-677-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001432103T00000X
MI5501012103225100000X
MI5201000891225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty