Provider Demographics
NPI:1962928234
Name:ABRAHAM, JOHN THOMAS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:ABRAHAM
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 1:148 BURTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3054
Mailing Address - Country:US
Mailing Address - Phone:248-217-9939
Mailing Address - Fax:
Practice Address - Street 1:5366 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-6018
Practice Address - Country:US
Practice Address - Phone:616-608-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician