Provider Demographics
NPI:1770218646
Name:THOMAS, THERESA (DNP, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DNP, APRN, PMHNP-BC
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 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:
Practice Address - Street 1:234 E GRAY ST STE 154
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1903
Practice Address - Country:US
Practice Address - Phone:502-899-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-23
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4012348363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health