Provider Demographics
NPI:1003439837
Name:THOMAS, LADAWNA ELYNNE
Entity Type:Individual
Prefix:
First Name:LADAWNA
Middle Name:ELYNNE
Last Name:THOMAS
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 1:1749 GRAPE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63147-1434
Mailing Address - Country:US
Mailing Address - Phone:314-614-1385
Mailing Address - Fax:
Practice Address - Street 1:3482 HOLLENBERG DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2429
Practice Address - Country:US
Practice Address - Phone:314-614-1385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200003151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty