Healthcare Provider Details

I. General information

NPI: 1497552970
Provider Name (Legal Business Name): MICHELLE THOMAS AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24783 MARION RIDGE DR
IDYLLWILD CA
92549-2377
US

IV. Provider business mailing address

9962 E 97TH ST
TULSA OK
74133-5126
US

V. Phone/Fax

Practice location:
  • Phone: 310-498-9011
  • Fax:
Mailing address:
  • Phone: 310-498-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number120062
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: