Provider Demographics
NPI:1558764670
Name:BOTTENFIELD, THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BOTTENFIELD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30200 TELEGRAPH RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4502
Mailing Address - Country:US
Mailing Address - Phone:248-712-1129
Mailing Address - Fax:248-569-9410
Practice Address - Street 1:19875 BUTTERNUT LN
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1795
Practice Address - Country:US
Practice Address - Phone:248-568-3711
Practice Address - Fax:248-569-9410
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007898103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical