Provider Demographics
NPI:1598109779
Name:THOMAS, CONNIE SUE (LMFT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 W CULVER AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4150
Mailing Address - Country:US
Mailing Address - Phone:714-371-7954
Mailing Address - Fax:
Practice Address - Street 1:1529 W CULVER AVE APT 16
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4150
Practice Address - Country:US
Practice Address - Phone:714-371-7954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT42408106H00000X
COMFT1033106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist