Provider Demographics
NPI:1336565035
Name:MARTIN-THAMES, TANITA (LCSW)
Entity Type:Individual
Prefix:
First Name:TANITA
Middle Name:
Last Name:MARTIN-THAMES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2358
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-2358
Mailing Address - Country:US
Mailing Address - Phone:913-915-6236
Mailing Address - Fax:
Practice Address - Street 1:2637 RIDGEWOOD RD STE G
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4971
Practice Address - Country:US
Practice Address - Phone:913-915-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC74891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical