Healthcare Provider Details

I. General information

NPI: 1447584578
Provider Name (Legal Business Name): ELAINE A THOMAS PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 ALEXANDER ST SE SUITE 6
MARIETTA GA
30060-8217
US

IV. Provider business mailing address

316 ALEXANDER ST SE SUITE 6
MARIETTA GA
30060-8217
US

V. Phone/Fax

Practice location:
  • Phone: 770-216-0460
  • Fax: 678-581-0146
Mailing address:
  • Phone: 770-216-0460
  • Fax: 678-581-0146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY#2936
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY#2936
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY#2936
License Number StateGA

VIII. Authorized Official

Name: DR. ELAINE ANGELA THOMAS
Title or Position: LICENSED PSYCHOLOGIST/OWNER
Credential: PSY.D.
Phone: 770-216-0460