Healthcare Provider Details

I. General information

NPI: 1215275698
Provider Name (Legal Business Name): MS. MARY ANN THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2013
Last Update Date: 01/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 AVENUE OF AMERICA
MONROE LA
71201-4530
US

IV. Provider business mailing address

1818 AVENUE OF AMERICA
MONROE LA
71201-4530
US

V. Phone/Fax

Practice location:
  • Phone: 318-998-2700
  • Fax: 318-998-2700
Mailing address:
  • Phone: 318-998-2700
  • Fax: 318-998-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5885
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: