Healthcare Provider Details

I. General information

NPI: 1265239503
Provider Name (Legal Business Name): MELISSA E THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2025
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 CENTER PLACE WAY
ST AUGUSTINE FL
32095-8859
US

IV. Provider business mailing address

89 MERCUTIO LN
ST AUGUSTINE FL
32092-4528
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-2179
  • Fax:
Mailing address:
  • Phone: 631-252-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: