Provider Demographics
NPI:1982696258
Name:TOMAC, MARY ELLEN (ACSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:TOMAC
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 ROE RD
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-9030
Mailing Address - Country:US
Mailing Address - Phone:734-475-9273
Mailing Address - Fax:
Practice Address - Street 1:3333 SPRING ARBOR RD
Practice Address - Street 2:STE 800
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-8605
Practice Address - Country:US
Practice Address - Phone:517-782-2442
Practice Address - Fax:517-782-0310
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801046899104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
089639778001Medicare ID - Type Unspecified