Provider Demographics
NPI:1376196246
Name:THOMAS, TINA M (INTERVENTION PRO)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:F
Credentials:INTERVENTION PRO
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:INTERVENTION PROF
Mailing Address - Street 1:3800 W PERUGIA ST APT W204
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4973
Mailing Address - Country:US
Mailing Address - Phone:208-869-7306
Mailing Address - Fax:
Practice Address - Street 1:3800 W PERUGIA ST APT W204
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4973
Practice Address - Country:US
Practice Address - Phone:208-869-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0003835Medicaid