=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912206756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISA MARGARET THOMAS MA, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2011
-----------------------------------------------------
Last Update Date | 04/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1571 BRUSHWOOD CT SE
-----------------------------------------------------
City | BOLIVIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28422-8189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-880-3080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4891 LONG BEACH RD SE STE 3
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-8712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-880-3080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 10344
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1738
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 10344
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------