MEDICARE: MS. LISETTA FLORENCE THOMAS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor
3	101YS0200X	School Counselor	NA	TX
4	101YM0800X	Mental Health Counselor	18376	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER	TX	SCHOOL COUNSELOR
2	42-1648622	OTHER	TX	FED TAX ID
3	18376	OTHER	TX	LPC
4	66915	OTHER	TX	NCC

General Provider Information

NPI Number	:	1588716138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISETTA FLORENCE THOMAS LPC

Provider Business Mailing Address
First Line	:	1516 HUNTING GREEN DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-5544
Country	:	US
Telephone Number	:	817-568-1419
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 COLLEGE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2270
Country	:	US
Telephone Number	:	917-817-5360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	01/30/2023

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