=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801094230
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REDONIA M THOMAS ACSW, LISW-CP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 W MAIN ST
-----------------------------------------------------
City | TAYLORS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29687-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-244-1007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 BROOKRIDGE AVE
-----------------------------------------------------
City | TAYLORS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29687-3997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-325-9282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2249
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------