Provider Demographics
NPI:1689091399
Name:LAWRENCE, THOMAS (MA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3302
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-3302
Mailing Address - Country:US
Mailing Address - Phone:248-881-8210
Mailing Address - Fax:
Practice Address - Street 1:16237 CARRIAGE LAMP CT APT 911
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3528
Practice Address - Country:US
Practice Address - Phone:248-881-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional