Provider Demographics
NPI:1679057590
Name:THOMAS, MARY ANN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
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 1:6163 ATLANTIC AVE STE 132
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-2922
Mailing Address - Country:US
Mailing Address - Phone:562-412-2077
Mailing Address - Fax:888-792-6665
Practice Address - Street 1:1775 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-1674
Practice Address - Country:US
Practice Address - Phone:562-412-2077
Practice Address - Fax:888-792-6665
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174H00000X, 246Y00000X
CA71767101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174H00000XOther Service ProvidersHealth Educator
No246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA150072238OtherADULT EDUCATION INSTRUCTOR
CA71767OtherCALIFORNIA CONSORTIUM OF ADDICTION PROGRAMS AND PROFESSIONAL
CA170063421OtherCHILD DEVELOPMENT PROGRAM DIRECTOR PERMIT