1639385263 NPI number — THORA GREAVES LMSW

Table of content: THORA GREAVES LMSW (NPI 1639385263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639385263 NPI number — THORA GREAVES LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREAVES
Provider First Name:
THORA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

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:
1639385263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 WATER ST
Provider Second Line Business Mailing Address:
SUITE #206
Provider Business Mailing Address City Name:
BENTON HARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49022-3451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-861-5084
Provider Business Mailing Address Fax Number:
269-934-0557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 WATER ST
Provider Second Line Business Practice Location Address:
SUITE #206
Provider Business Practice Location Address City Name:
BENTON HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49022-3451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-861-5084
Provider Business Practice Location Address Fax Number:
269-934-0557
Provider Enumeration Date:
05/14/2007

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: 101YM0800X , with the licence number:  6801077510 , 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)

  • Identifier: 639385263 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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