Provider Demographics
NPI:1639434111
Name:THACK, BETTY JANE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JANE
Last Name:THACK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 WOODGATE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5526
Mailing Address - Country:US
Mailing Address - Phone:248-528-9395
Mailing Address - Fax:
Practice Address - Street 1:1787 W BIG BEAVER RD
Practice Address - Street 2:SUITE 170
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3548
Practice Address - Country:US
Practice Address - Phone:248-971-0383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional