Provider Demographics
NPI:1669505855
Name:THOMASON, MICHELE LEA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:LEA
Last Name:THOMASON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 DALE RD APT 27
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8601
Mailing Address - Country:US
Mailing Address - Phone:209-595-9735
Mailing Address - Fax:
Practice Address - Street 1:1620 CUMMINS DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-6400
Practice Address - Country:US
Practice Address - Phone:209-595-9735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21141103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical