Provider Demographics
NPI:1326172727
Name:THOMAS, MARY MICHELE (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHELE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:BURHARD
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1011 LEHMAN AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-6515
Mailing Address - Country:US
Mailing Address - Phone:270-843-8233
Mailing Address - Fax:270-393-9835
Practice Address - Street 1:1011 LEHMAN AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-6515
Practice Address - Country:US
Practice Address - Phone:270-843-8233
Practice Address - Fax:270-393-9835
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPSYCHOLOGIST 1311103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000358793OtherANTHEM BC BLUE SHIELD
KY0956701Medicare ID - Type Unspecified