Provider Demographics
NPI:1598047078
Name:THOMAS, AGNES (OTR)
Entity Type:Individual
Prefix:MRS
First Name:AGNES
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 CHARLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-3625
Mailing Address - Country:US
Mailing Address - Phone:124-865-1412
Mailing Address - Fax:
Practice Address - Street 1:25811 W 12 MILE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1896
Practice Address - Country:US
Practice Address - Phone:124-835-6741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007689225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist