Provider Demographics
NPI:1407165822
Name:THELEN, ELIZABETH GARY (LMSW, CAADC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:GARY
Last Name:THELEN
Suffix:
Gender:F
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5631 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:MI
Mailing Address - Zip Code:48851-9792
Mailing Address - Country:US
Mailing Address - Phone:616-822-4603
Mailing Address - Fax:
Practice Address - Street 1:375 APPLE TREE DR
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-7506
Practice Address - Country:US
Practice Address - Phone:616-527-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801092492104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker