Basic Information
| Provider Information | |||||||||
| NPI: | 1821244807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 454 | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719290401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018653363 | ||||||||
| FaxNumber: | 5018653362 | ||||||||
| Practice Location | |||||||||
| Address1: | 3399 FINCH RD | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719297541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018653363 | ||||||||
| FaxNumber: | 5018653362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2008 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.