Provider Demographics
NPI:1801041488
Name:THOMAS, MICHELLE R (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 KILBOURN ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1920
Mailing Address - Country:US
Mailing Address - Phone:574-266-8066
Mailing Address - Fax:574-255-1882
Practice Address - Street 1:1750 KILBOURN ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1920
Practice Address - Country:US
Practice Address - Phone:574-266-8066
Practice Address - Fax:574-266-8066
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340055941041C0700X
IN34005594A101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000716598OtherANTHEM
IN000000716598OtherANTHEM
INP00987346Medicare PIN