Provider Demographics
NPI:1174029235
Name:THOMAS, MARILYN (MHS, CADAC IV, LCAC)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MHS, CADAC IV, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 W 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406-2821
Mailing Address - Country:US
Mailing Address - Phone:773-350-0148
Mailing Address - Fax:
Practice Address - Street 1:1100 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1711
Practice Address - Country:US
Practice Address - Phone:219-885-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)