MEDICARE: MISS EUNICE D THOMAS MLC

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	101YM0800X	Mental Health Counselor	IMH5930	FL

General Provider Information

NPI Number	:	1194128942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS EUNICE D THOMAS MLC

Provider Business Mailing Address
First Line	:	15001 HAWKS SHADOW DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-2444
Country	:	US
Telephone Number	:	941-276-6614
Fax Number	:	239-693-0285

Provider Business Practice Location Address
First Line	:	15001 HAWKS SHADOW DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-2444
Country	:	US
Telephone Number	:	941-276-6614
Fax Number	:	239-693-0285

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

Provider Enumeration Date	:	10/07/2014
Last Update Date	:	10/07/2014

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