Basic Information
| Provider Information | |||||||||
| NPI: | 1245254275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | CHARLA | ||||||||
| MiddleName: | ELLIOTT | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 CALLE LEJANO | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875018910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059958894 | ||||||||
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| Practice Location | |||||||||
| Address1: | 820 PASEO DE PERALTA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059869633 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I-4032 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.