Provider Demographics
NPI:1588195739
Name:TOMAK, MICHAEL (PHD, BCBA-D, LBA)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:TOMAK
Suffix:
Gender:M
Credentials:PHD, BCBA-D, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N JOHN ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MI
Mailing Address - Zip Code:49045-1365
Mailing Address - Country:US
Mailing Address - Phone:269-330-0696
Mailing Address - Fax:
Practice Address - Street 1:23200 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-7774
Practice Address - Country:US
Practice Address - Phone:269-355-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401000344103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7401000344OtherBEHAVIOR ANALYST LICENSE
1-17-26425OtherBEHAVIOR ANALYST CERTIFICATION