Provider Demographics
NPI:1821505942
Name:THAMES, TA-TANEISHA
Entity Type:Individual
Prefix:
First Name:TA-TANEISHA
Middle Name:
Last Name:THAMES
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 1:17805 COTTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-7446
Mailing Address - Country:US
Mailing Address - Phone:310-480-8062
Mailing Address - Fax:310-982-2144
Practice Address - Street 1:17805 COTTONWOOD CT
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-7446
Practice Address - Country:US
Practice Address - Phone:310-480-8062
Practice Address - Fax:310-982-2144
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool