Provider Demographics
NPI:1073916235
Name:THOMAS, ELLEN (LMFT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2422
Mailing Address - Country:US
Mailing Address - Phone:478-464-3003
Mailing Address - Fax:
Practice Address - Street 1:304 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2422
Practice Address - Country:US
Practice Address - Phone:478-464-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAMFT000302106H00000X
GAMFT001400106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist