Provider Demographics
NPI:1710652748
Name:THOMAS, CASSANDRA MARIE
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 W WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2863
Mailing Address - Country:US
Mailing Address - Phone:248-707-4339
Mailing Address - Fax:248-499-7081
Practice Address - Street 1:29548 SOUTHFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2028
Practice Address - Country:US
Practice Address - Phone:313-603-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009361103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical