Provider Demographics
NPI:1588657852
Name:THOMAS, TISON (MSW)
Entity Type:Individual
Prefix:
First Name:TISON
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25925 TELEGRAPH RD
Mailing Address - Street 2:210
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2518
Mailing Address - Country:US
Mailing Address - Phone:248-746-0342
Mailing Address - Fax:248-746-0308
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:DEPT OF BEHAVIORAL MEDICINE
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3330
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801072773101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor