Provider Demographics
NPI:1699045542
Name:THOMAS, AMY RENAE (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RENAE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8880
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-0880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2390 KANAWHA STATE FOREST DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-9080
Practice Address - Country:US
Practice Address - Phone:304-389-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid