Healthcare Provider Details

I. General information

NPI: 1992637896
Provider Name (Legal Business Name): DESIRAY THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DESIRAY HENDERSON

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 S GEORGE AVE
PETAL MS
39465-2028
US

IV. Provider business mailing address

414 S GEORGE AVE
PETAL MS
39465-2028
US

V. Phone/Fax

Practice location:
  • Phone: 813-764-3253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number101534
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: