Provider Demographics
NPI:1255724753
Name:THOMASON, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:THOMASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183166
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48318
Mailing Address - Country:US
Mailing Address - Phone:586-484-9111
Mailing Address - Fax:586-200-0118
Practice Address - Street 1:7755 22 MILE RD #183166
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48318
Practice Address - Country:US
Practice Address - Phone:586-484-9111
Practice Address - Fax:586-200-0118
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008057173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501008057OtherSTATE LICENSE