Provider Demographics
NPI:1861503112
Name:PETTUS, THOMAS BERNARD (LLPC, LBSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BERNARD
Last Name:PETTUS
Suffix:
Gender:M
Credentials:LLPC, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25153 LINDENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-6189
Mailing Address - Country:US
Mailing Address - Phone:313-702-1459
Mailing Address - Fax:
Practice Address - Street 1:25153 LINDENWOOD LN
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6189
Practice Address - Country:US
Practice Address - Phone:313-702-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008172101Y00000X
MI6802061866104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801061866OtherSTATE LICENSE
MI6401008172OtherST OF MI-COUNSELING LICENSE