Provider Demographics
NPI:1235594284
Name:BETTY J THACK MA PLLC
Entity Type:Organization
Organization Name:BETTY J THACK MA PLLC
Other - Org Name:BETTY THACK MA LPC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNSELOR/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:THACK
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC NCC
Authorized Official - Phone:248-761-9771
Mailing Address - Street 1:711 WEST THIRTEEN MILE RD
Mailing Address - Street 2:BETTY THACK MA LPC
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071
Mailing Address - Country:US
Mailing Address - Phone:248-761-9771
Mailing Address - Fax:
Practice Address - Street 1:711 WEST THIRTEEN MILE RD
Practice Address - Street 2:BETTY THACK MA LPC
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071
Practice Address - Country:US
Practice Address - Phone:248-761-9771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2016-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009796251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health