Provider Demographics
NPI:1770944365
Name:THRELKELD, ANDRE
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:THRELKELD
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 1:61 S ASTOR ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2910
Mailing Address - Country:US
Mailing Address - Phone:313-778-5587
Mailing Address - Fax:
Practice Address - Street 1:2925 RUSSELL
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-396-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802071857101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health