Provider Demographics
NPI:1952634420
Name:THOMAS, SHELISSA F (CDC1)
Entity Type:Individual
Prefix:
First Name:SHELISSA
Middle Name:F
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CDC1
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 82321
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-2321
Mailing Address - Country:US
Mailing Address - Phone:907-457-2176
Mailing Address - Fax:907-457-2196
Practice Address - Street 1:542 4TH AVE STE B101
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-374-1097
Practice Address - Fax:907-457-2196
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
AK3185101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK251C00000XMedicaid
AK251C00000XOtherCARE COORDINATOR ADMINISTRATOR
AK3185OtherADDICTION COUNSELOR