Provider Demographics
NPI:1346488608
Name:THOMAS, MARK WHITTED (MA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WHITTED
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 MASON ST
Mailing Address - Street 2:STUITE 212
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-4546
Mailing Address - Country:US
Mailing Address - Phone:707-448-0499
Mailing Address - Fax:
Practice Address - Street 1:419 MASON ST
Practice Address - Street 2:STUITE 212
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-4546
Practice Address - Country:US
Practice Address - Phone:707-448-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-25
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69029106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist