Provider Demographics
NPI:1700336591
Name:THOMAS, CLARA (BA,PP,CPS)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:BA,PP,CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6572 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-5246
Mailing Address - Country:US
Mailing Address - Phone:912-282-4192
Mailing Address - Fax:
Practice Address - Street 1:6572 BAILEY RD
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-5246
Practice Address - Country:US
Practice Address - Phone:912-282-4192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2016 0D0247251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health