Provider Demographics
NPI:1205184751
Name:WRIGHT, THALIA ANGELIQUE
Entity Type:Individual
Prefix:
First Name:THALIA
Middle Name:ANGELIQUE
Last Name:WRIGHT
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 1:901 WASHINGTON AVE
Mailing Address - Street 2:1B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-1041
Mailing Address - Country:US
Mailing Address - Phone:718-399-9746
Mailing Address - Fax:
Practice Address - Street 1:901 WASHINGTON AVE
Practice Address - Street 2:1B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-1041
Practice Address - Country:US
Practice Address - Phone:718-399-9746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1773250174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist