Healthcare Provider Details

I. General information

NPI: 1679057590
Provider Name (Legal Business Name): MARY ANN THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 CHESTNUT AVE
LONG BEACH CA
90813-1674
US

IV. Provider business mailing address

6163 ATLANTIC AVE STE 132
LONG BEACH CA
90805-2922
US

V. Phone/Fax

Practice location:
  • Phone: 562-412-2077
  • Fax: 888-792-6665
Mailing address:
  • Phone: 562-412-2077
  • Fax: 888-792-6665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number71767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: