Provider Demographics
NPI:1265706733
Name:THOMAS, EDWINA
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:
Last Name:THOMAS
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 1:7731 OLD CANTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6115
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:601-499-0936
Practice Address - Street 1:401 BAPTIST DR STE 301
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2012
Practice Address - Country:US
Practice Address - Phone:601-499-0935
Practice Address - Fax:601-499-0936
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1967101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional