Provider Demographics
NPI:1942707831
Name:THICK, CHANCE MATTHEW
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:MATTHEW
Last Name:THICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 WINEGAR RD
Mailing Address - Street 2:
Mailing Address - City:BANCROFT
Mailing Address - State:MI
Mailing Address - Zip Code:48414-9756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4273 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5321
Practice Address - Country:US
Practice Address - Phone:989-953-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)