1255881066 NPI number — MR. THOMAS MARK HALES M.ED, BCBA

Table of content: MR. THOMAS MARK HALES M.ED, BCBA (NPI 1255881066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255881066 NPI number — MR. THOMAS MARK HALES M.ED, BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALES
Provider First Name:
THOMAS
Provider Middle Name:
MARK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.ED, BCBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255881066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4893 EAST BELTLINE AVE NE
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-901-5478
Provider Business Mailing Address Fax Number:
616-591-3393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4893 EAST BELTLINE AVE
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-901-5478
Provider Business Practice Location Address Fax Number:
166-591-3393
Provider Enumeration Date:
10/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-16-23859 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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