Provider Demographics
NPI:1740604370
Name:THOMAS, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 E RIVERSIDE DR
Mailing Address - Street 2:SUITE G3
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:
Practice Address - Street 1:2401 E RIVERSIDE DR
Practice Address - Street 2:SUITE G3
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701
Practice Address - Country:US
Practice Address - Phone:512-445-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64438101YP2500X
TX201278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist