Provider Demographics
NPI:1417472630
Name:THOMAS, GRACE JESSIE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:JESSIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:JESSIE
Other - Last Name:RAULSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCDC
Mailing Address - Street 1:4459 W US HIGHWAY 82
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-8046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1216 N CENTRAL EXPY STE 208
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-3328
Practice Address - Country:US
Practice Address - Phone:469-298-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10837101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)