Provider Demographics
NPI:1740420694
Name:THOMAS, FAYTRENE (MSE, CCC-SP)
Entity Type:Individual
Prefix:
First Name:FAYTRENE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MSE, CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601-7811
Mailing Address - Country:US
Mailing Address - Phone:870-536-4369
Mailing Address - Fax:870-536-4369
Practice Address - Street 1:318 W 24TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-7811
Practice Address - Country:US
Practice Address - Phone:870-536-4369
Practice Address - Fax:870-536-4369
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR461235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist