Provider Demographics
NPI:1053886275
Name:THOMAS, MYIA MARIE
Entity type:Individual
Prefix:
First Name:MYIA
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 CROSS PONITE SUITE L
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230
Mailing Address - Country:US
Mailing Address - Phone:614-596-3176
Mailing Address - Fax:
Practice Address - Street 1:431 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215
Practice Address - Country:US
Practice Address - Phone:614-227-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171M00000XMedicaid