Provider Demographics
NPI:1982377446
Name:THOMAS, TANISHA (LLMSSW)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LLMSSW
Other - Prefix:
Other - First Name:TANISHA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LLMSW
Mailing Address - Street 1:24913 RAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3452
Mailing Address - Country:US
Mailing Address - Phone:586-339-7706
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:586-339-7706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511100201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6851110020Medicaid