Provider Demographics
NPI:1578004628
Name:THOMAS, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17630 LAKEWOOD BLVD APT 29
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-6465
Mailing Address - Country:US
Mailing Address - Phone:702-517-2712
Mailing Address - Fax:
Practice Address - Street 1:17630 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-6472
Practice Address - Country:US
Practice Address - Phone:702-517-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician