Provider Demographics
NPI:1720180912
Name:THOMAS, MARY E (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:BONENBERGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5 SAN PABLO LANE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-871-2770
Mailing Address - Fax:
Practice Address - Street 1:4500 WEST MIDWAY ROAD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981
Practice Address - Country:US
Practice Address - Phone:772-468-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW77771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical