Provider Demographics
NPI:1811346315
Name:THOMAS, TINA (LPC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 W GLADE CREEK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4310
Mailing Address - Country:US
Mailing Address - Phone:208-941-3142
Mailing Address - Fax:
Practice Address - Street 1:1860 W GLADE CREEK ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4310
Practice Address - Country:US
Practice Address - Phone:208-941-3142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6182101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health