Healthcare Provider Details

I. General information

NPI: 1497464556
Provider Name (Legal Business Name): KEAYON DONTRE THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 GUMBERRY CT
HOPE MILLS NC
28348-8421
US

IV. Provider business mailing address

1865 GUMBERRY CT
HOPE MILLS NC
28348-8421
US

V. Phone/Fax

Practice location:
  • Phone: 910-710-4520
  • Fax:
Mailing address:
  • Phone: 910-710-4520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: