Provider Demographics
NPI:1629567151
Name:THOMAS, SHARIF AHKEEM JAMAL
Entity Type:Individual
Prefix:
First Name:SHARIF AHKEEM
Middle Name:JAMAL
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 1:3 FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-4203
Mailing Address - Country:US
Mailing Address - Phone:781-439-2179
Mailing Address - Fax:
Practice Address - Street 1:3 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-4203
Practice Address - Country:US
Practice Address - Phone:781-439-2179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CDW982645665OtherBLUE CROSS BLUE SHIELD