Provider Demographics
NPI:1093493728
Name:THOMAS, SHEA LARON
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:LARON
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 1:251 FAIRVIEW CHASE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-1137
Mailing Address - Country:US
Mailing Address - Phone:704-935-6810
Mailing Address - Fax:
Practice Address - Street 1:251 FAIRVIEW CHASE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-1137
Practice Address - Country:US
Practice Address - Phone:704-935-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician