Provider Demographics
NPI:1922300227
Name:THOMAS, PENELOPE S (CDP)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:S
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4013 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4830
Mailing Address - Country:US
Mailing Address - Phone:425-478-4571
Mailing Address - Fax:360-651-4404
Practice Address - Street 1:2821 MISSION HILL RD
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-9706
Practice Address - Country:US
Practice Address - Phone:360-716-4334
Practice Address - Fax:360-652-4404
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00000479101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)