Healthcare Provider Details

I. General information

NPI: 1922300227
Provider Name (Legal Business Name): PENELOPE S THOMAS CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 MISSION HILL RD
TULALIP WA
98271-9706
US

IV. Provider business mailing address

4013 HIGH ST
EVERETT WA
98201-4830
US

V. Phone/Fax

Practice location:
  • Phone: 360-716-4334
  • Fax: 360-652-4404
Mailing address:
  • Phone: 425-478-4571
  • Fax: 360-651-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00000479
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: