Provider Demographics
NPI:1275049918
Name:DAUBENSPECK, THOM
Entity Type:Individual
Prefix:
First Name:THOM
Middle Name:
Last Name:DAUBENSPECK
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 1:308 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4035
Mailing Address - Country:US
Mailing Address - Phone:616-610-2748
Mailing Address - Fax:
Practice Address - Street 1:483 CENTURY LN
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4286
Practice Address - Country:US
Practice Address - Phone:616-396-5284
Practice Address - Fax:616-610-2748
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011019711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical