Provider Demographics
NPI:1649236274
Name:HALLER, THOMAS BRUCE (LMSW, ACSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BRUCE
Last Name:HALLER
Suffix:
Gender:M
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 KABOBEL DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604
Mailing Address - Country:US
Mailing Address - Phone:989-791-4191
Mailing Address - Fax:789-791-4191
Practice Address - Street 1:3070 KABOBEL DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604
Practice Address - Country:US
Practice Address - Phone:989-791-4191
Practice Address - Fax:989-791-4191
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010650921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008949790OtherBLUE CROSS
MI112622OtherVALUE OPTIONS
MIOM65420Medicare PIN