Provider Demographics
NPI:1346064540
Name:THOMAS, TERRY JACOB (TLLP)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:JACOB
Last Name:THOMAS
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33298 TRAFALGAR SQ APT 5
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-4860
Mailing Address - Country:US
Mailing Address - Phone:313-957-8478
Mailing Address - Fax:
Practice Address - Street 1:33298 TRAFALGAR SQ APT 5
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-4860
Practice Address - Country:US
Practice Address - Phone:313-957-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical