=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144686726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRACY W THOMAS, LPC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2016
-----------------------------------------------------
Last Update Date | 01/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 N ALAMO BLVD
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75670-3455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-407-9701
-----------------------------------------------------
Fax | 888-845-9293
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 N ALAMO BLVD
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75670-3455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-407-9701
-----------------------------------------------------
Fax | 888-845-9293
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MR. TRACY WAYNE THOMAS
-----------------------------------------------------
Credential | LPC-S
-----------------------------------------------------
Telephone | 903-407-9701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 19851
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------