Healthcare Provider Details

I. General information

NPI: 1346071453
Provider Name (Legal Business Name): AUDREY NICOLE THOMAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

90 HOPE DR #6000
MOUNTAIN HOME ID
83647
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-6806
  • Fax:
Mailing address:
  • Phone: 208-828-6806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103254
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6461071
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: