Provider Demographics
NPI: | 1790299295 |
---|---|
Name: | THOMAS, SHATORIA TYSHON (LCMHCA, LCASA) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHATORIA |
Middle Name: | TYSHON |
Last Name: | THOMAS |
Suffix: | |
Gender: | F |
Credentials: | LCMHCA, LCASA |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 100 BILLINGSLEY RD |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28211-1002 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 704-376-7447 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 429 BILLINGSLEY RD |
Practice Address - Street 2: | |
Practice Address - City: | CHARLOTTE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28211-1007 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-445-6900 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2017-11-21 |
Last Update Date: | 2020-03-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | LCAS-22433 | 101YA0400X |
NC | A13369 | 101YM0800X |
101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |