=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629286729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS J KEBBA MA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 PASTEUR DR STE 405
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27403-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-852-0626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6003 QUAIL RIDGE DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27455-9231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-202-5419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4136
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------