Provider Demographics
NPI:1972847119
Name:THOMAS, DAVID MALCOM
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MALCOM
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 IMPERIAL PKWY
Mailing Address - Street 2:SUITE 128
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-8476
Mailing Address - Country:US
Mailing Address - Phone:863-214-8653
Mailing Address - Fax:863-937-9210
Practice Address - Street 1:5925 IMPERIAL PKWY
Practice Address - Street 2:SUITE 128
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-8476
Practice Address - Country:US
Practice Address - Phone:863-214-8653
Practice Address - Fax:863-937-9210
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-10
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT1596106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist