MEDICARE: MRS. MAVIS THOMAS LPC-S

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	101Y00000X	Counselor	69372	TX
2	101YP2500X	Professional Counselor	69372	TX
3	101YM0800X	Mental Health Counselor	69372	TX

General Provider Information

NPI Number	:	1437573094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MAVIS THOMAS LPC-S

Provider Business Mailing Address
First Line	:	4980 GARDEN GROVE RD
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-4400
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1506 W PIONEER PKWY
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-6230
Country	:	US
Telephone Number	:	832-613-5609
Fax Number	:

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

Provider Enumeration Date	:	02/18/2014
Last Update Date	:	11/02/2023

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