Provider Demographics
NPI:1336571058
Name:THOMAS, SHARONDA C (MED, MHP)
Entity Type:Individual
Prefix:MS
First Name:SHARONDA
Middle Name:C
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MED, MHP
Other - Prefix:MS
Other - First Name:SHARONDA
Other - Middle Name:
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:2620 CENTENARY BLVD STE 312
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3358
Mailing Address - Country:US
Mailing Address - Phone:318-681-9935
Mailing Address - Fax:318-681-9938
Practice Address - Street 1:2620 CENTENARY BLVD STE 312
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3358
Practice Address - Country:US
Practice Address - Phone:318-681-9935
Practice Address - Fax:318-681-9938
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
LA171M00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1336571058Medicaid