Provider Demographics
NPI:1679319032
Name:THOMAS, LETARA
Entity type:Individual
Prefix:
First Name:LETARA
Middle Name:
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 1:4306 COUNTY ROAD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4306 COUNTY ROAD 7714
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36081-8619
Practice Address - Country:US
Practice Address - Phone:334-312-7393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLPC05149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional