Provider Demographics
NPI:1639385263
Name:GREAVES, THORA (LMSW)
Entity Type:Individual
Prefix:
First Name:THORA
Middle Name:
Last Name:GREAVES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WATER ST
Mailing Address - Street 2:SUITE #206
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-3451
Mailing Address - Country:US
Mailing Address - Phone:269-861-5084
Mailing Address - Fax:269-934-0557
Practice Address - Street 1:107 WATER ST
Practice Address - Street 2:SUITE #206
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3451
Practice Address - Country:US
Practice Address - Phone:269-861-5084
Practice Address - Fax:269-934-0557
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801077510101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI639385263Medicaid