Healthcare Provider Details

I. General information

NPI: 1720180912
Provider Name (Legal Business Name): MARY E THOMAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. MARY E BONENBERGER

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 WEST MIDWAY ROAD
FORT PIERCE FL
34981
US

IV. Provider business mailing address

5 SAN PABLO LANE
PORT ST LUCIE FL
34952
US

V. Phone/Fax

Practice location:
  • Phone: 772-468-5600
  • Fax:
Mailing address:
  • Phone: 772-871-2770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW7777
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: