Provider Demographics
NPI:1568585255
Name:LABERTEAUX, THOMAS E (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:LABERTEAUX
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 1:4670 FULTON ST E STE 101
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8409
Mailing Address - Country:US
Mailing Address - Phone:616-975-3160
Mailing Address - Fax:616-975-3163
Practice Address - Street 1:4670 FULTON ST E STE 101
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8409
Practice Address - Country:US
Practice Address - Phone:616-975-3160
Practice Address - Fax:616-975-3163
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000979103T00000X, 103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD145249682Medicare ID - Type Unspecified
MIR67289Medicare UPIN