Provider Demographics
NPI:1104842145
Name:THOMAS, PATTI DALE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PATTI
Middle Name:DALE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SAMOA BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6604
Mailing Address - Country:US
Mailing Address - Phone:707-882-0370
Mailing Address - Fax:707-822-1171
Practice Address - Street 1:920 SAMOA BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6604
Practice Address - Country:US
Practice Address - Phone:707-882-0370
Practice Address - Fax:707-822-1171
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA222441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS222440OtherBLUE SHIELD
CAZZZ32392ZMedicare ID - Type Unspecified