Provider Demographics
NPI:1861529604
Name:FARIS, THEODORE PAUL (MA, LPC)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:PAUL
Last Name:FARIS
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3689 DARCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2126
Mailing Address - Country:US
Mailing Address - Phone:248-644-0253
Mailing Address - Fax:248-644-0253
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:SUITE 2160
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-960-5106
Practice Address - Fax:248-960-5532
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2009-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008983101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health