Provider Demographics
NPI:1467489914
Name:SPAHN, THOMAS (EDD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SPAHN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 OTTAWA AVE NW
Mailing Address - Street 2:SUITE 300C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2701
Mailing Address - Country:US
Mailing Address - Phone:616-458-0692
Mailing Address - Fax:616-458-8129
Practice Address - Street 1:161 OTTAWA AVE NW
Practice Address - Street 2:SUITE 300C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2701
Practice Address - Country:US
Practice Address - Phone:616-458-0692
Practice Address - Fax:616-458-8129
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006402103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D14599Medicare ID - Type Unspecified