Provider Demographics
NPI:1710158969
Name:THOMAS, GERALDINE E (MASTERS IN REHAB COU)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:E
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MASTERS IN REHAB COU
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 ST MATTHEWS ROAD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118
Mailing Address - Country:US
Mailing Address - Phone:803-536-1571
Mailing Address - Fax:803-536-1463
Practice Address - Street 1:5573 CAROLINA HIGHWAY
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:SC
Practice Address - Zip Code:29042
Practice Address - Country:US
Practice Address - Phone:803-793-4274
Practice Address - Fax:803-793-4275
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2765104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC413093Medicaid