Provider Demographics
NPI:1497931026
Name:THOMAS, ANDREA L (LISW-CP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711-A ST. ANDREW BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5983
Mailing Address - Country:US
Mailing Address - Phone:843-901-9309
Mailing Address - Fax:843-414-7572
Practice Address - Street 1:711 SAINT ANDREWS BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7196
Practice Address - Country:US
Practice Address - Phone:843-901-9309
Practice Address - Fax:843-414-7572
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC55231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQM0454Medicaid
Q31904Medicare UPIN
Q319048854Medicare PIN