Provider Demographics
NPI:1912985029
Name:THOMAS, MELVIN RUSSELL (PHD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:RUSSELL
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PHD
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 211
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:NC
Mailing Address - Zip Code:28478-0211
Mailing Address - Country:US
Mailing Address - Phone:910-441-7080
Mailing Address - Fax:910-552-5006
Practice Address - Street 1:7190 NC HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:NC
Practice Address - Zip Code:28478-7062
Practice Address - Country:US
Practice Address - Phone:910-441-7080
Practice Address - Fax:910-552-5006
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2926103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000679Medicaid
NC046EGOtherBCBS NC
62-00242OtherEVERCARE
NC046EGOtherBCBS NC
62-00242OtherEVERCARE