Provider Demographics
NPI:1225596323
Name:THOMAS, TOSHIBA
Entity Type:Individual
Prefix:
First Name:TOSHIBA
Middle Name:
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 1:900 SE OCEAN BLVD STE 130D
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3503
Mailing Address - Country:US
Mailing Address - Phone:772-219-7575
Mailing Address - Fax:
Practice Address - Street 1:900 SE OCEAN BLVD STE 130D
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3503
Practice Address - Country:US
Practice Address - Phone:772-219-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102442200Medicaid