Provider Demographics
NPI:1518744168
Name:THOMAS, DIANE MARIE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
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 1:1000 MT HOLLY HUNTERSVILLE RD # B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-9309
Mailing Address - Country:US
Mailing Address - Phone:631-448-9725
Mailing Address - Fax:
Practice Address - Street 1:1000 MT HOLLY HUNTERSVILLE RD # B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214-9309
Practice Address - Country:US
Practice Address - Phone:631-448-9725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service