Healthcare Provider Details

I. General information

NPI: 1689786758
Provider Name (Legal Business Name): ROBERT GORDON THOMAS MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 CHERAW HWY TRI COUNTY COMMUNITY MENTAL HEALTH
BENNETTSVILLE SC
29512
US

IV. Provider business mailing address

PO BOX 918
BENNETTSVILLE SC
29512
US

V. Phone/Fax

Practice location:
  • Phone: 843-454-0841
  • Fax: 843-454-0635
Mailing address:
  • Phone: 843-454-0841
  • Fax: 843-454-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: