Provider Demographics
NPI:1255900254
Name:THOMAS, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
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 1:12546 PROMENADE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-1416
Mailing Address - Country:US
Mailing Address - Phone:313-624-7712
Mailing Address - Fax:
Practice Address - Street 1:28303 DEQUINDRE RD STE 100
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3040
Practice Address - Country:US
Practice Address - Phone:248-658-1116
Practice Address - Fax:248-658-1120
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)