Provider Demographics
NPI:1134299589
Name:THOMAS, AGATHA RENE (BS, BHRS, CM)
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:RENE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:BS, BHRS, CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT. 1, BOX 122
Mailing Address - Street 2:
Mailing Address - City:BOLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74829
Mailing Address - Country:US
Mailing Address - Phone:918-667-3770
Mailing Address - Fax:
Practice Address - Street 1:RR 1, BOX 35D
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829
Practice Address - Country:US
Practice Address - Phone:918-667-3367
Practice Address - Fax:918-667-3387
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK#7176171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator