1699897728 NPI number — DR. THEADIA LARUE CAREY MD

Table of content: DR. THEADIA LARUE CAREY MD (NPI 1699897728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699897728 NPI number — DR. THEADIA LARUE CAREY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAREY
Provider First Name:
THEADIA
Provider Middle Name:
LARUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARTER
Provider Other First Name:
THEADIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699897728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22200 W. 11 MILE RD #181
Provider Second Line Business Mailing Address:
T. L. C. BEHAVIORAL SERVICES, PLLC
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-838-9852
Provider Business Mailing Address Fax Number:
866-769-2876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24424 W MCNICHOLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48219-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-255-0900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2007

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: 2084P0800X , with the licence number:  4301076021 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0802X , with the licence number: 4301076021 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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