Provider Demographics
NPI:1790009157
Name:THOMAS, MATTIE BELL (NON MEDICAL)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:BELL
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NON MEDICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 BELVEDERE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-2152
Mailing Address - Country:US
Mailing Address - Phone:904-764-0593
Mailing Address - Fax:904-764-0647
Practice Address - Street 1:2220 BELVEDERE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-2152
Practice Address - Country:US
Practice Address - Phone:904-764-0593
Practice Address - Fax:904-764-0647
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320700000X320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities