MEDICARE: CARLENE THOMAS MS ED, CRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	00115429	NY

General Provider Information

NPI Number	:	1003245978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLENE THOMAS MS ED, CRC

Provider Business Mailing Address
First Line	:	267 PORT RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-1704
Country	:	US
Telephone Number	:	718-981-8117
Fax Number	:

Provider Business Practice Location Address
First Line	:	267 PORT RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-1704
Country	:	US
Telephone Number	:	718-981-8117
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2013
Last Update Date	:	11/01/2013

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