Healthcare Provider Details

I. General information

NPI: 1023853223
Provider Name (Legal Business Name): MELINDA THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 BLACKLOG RD
INEZ KY
41224-9113
US

IV. Provider business mailing address

3165 BLACKLOG RD
INEZ KY
41224-9113
US

V. Phone/Fax

Practice location:
  • Phone: 606-534-4002
  • Fax:
Mailing address:
  • Phone: 606-534-4002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number289784
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: