Provider Demographics
NPI:1942593124
Name:THOMAS, TAISIYA TESS (LCMHC)
Entity Type:Individual
Prefix:
First Name:TAISIYA
Middle Name:TESS
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:TAISIYA
Other - Middle Name:
Other - Last Name:LARINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 1103
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-1103
Mailing Address - Country:US
Mailing Address - Phone:802-505-9151
Mailing Address - Fax:802-229-8004
Practice Address - Street 1:105 N MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-3791
Practice Address - Country:US
Practice Address - Phone:802-505-9151
Practice Address - Fax:802-448-2729
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171M00000X
VT068.0097993101YM0800X, 101YM0800X
4259218171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6710686Medicaid