Provider Demographics
NPI:1699040717
Name:THOMAS, CHAUNNA (LCPC)
Entity Type:Individual
Prefix:
First Name:CHAUNNA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 EDGEWOOD RD STE 210
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-2734
Mailing Address - Country:US
Mailing Address - Phone:443-402-0172
Mailing Address - Fax:
Practice Address - Street 1:500 EDGEWOOD RD STE 210
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-2734
Practice Address - Country:US
Practice Address - Phone:443-402-0172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8470101YP2500X
MDMH- 1044, MH-1043251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4210018OtherMEDICAID PROVIDER NUMBER