Provider Demographics
NPI:1023747011
Name:THOMAS, DIANA DESHAWN (MAADAC1, CPS)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:DESHAWN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MAADAC1, CPS
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:DESHAWN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MAADAC1, CPS
Mailing Address - Street 1:2551 W KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-2034
Mailing Address - Country:US
Mailing Address - Phone:417-210-6025
Mailing Address - Fax:417-869-4280
Practice Address - Street 1:2551 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2034
Practice Address - Country:US
Practice Address - Phone:417-210-6025
Practice Address - Fax:417-869-4280
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14230101YA0400X
MO14531101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)