Healthcare Provider Details

I. General information

NPI: 1730295122
Provider Name (Legal Business Name): DESHENA D. THOMAS ATC, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17527 JORDAN STREET
CHATOM AL
36518
US

IV. Provider business mailing address

391 SADIE LOOP
LUCEDALE MS
39452-1962
US

V. Phone/Fax

Practice location:
  • Phone: 251-847-3955
  • Fax: 251-847-3988
Mailing address:
  • Phone: 251-463-5052
  • Fax: 251-847-3988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number783
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: