Provider Demographics
NPI:1336673961
Name:THOMAS, KEYAISHA
Entity Type:Individual
Prefix:
First Name:KEYAISHA
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 1:56380 BICKHAM CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-4018
Mailing Address - Country:US
Mailing Address - Phone:985-474-2446
Mailing Address - Fax:
Practice Address - Street 1:5150 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2620
Practice Address - Country:US
Practice Address - Phone:985-206-5503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator