Basic Information
| Provider Information | |||||||||
| NPI: | 1437288974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | SHARI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | UEBAUTZ | ||||||||
| OtherFirstName: | SHARI | ||||||||
| OtherMiddleName: | HOPE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 W PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333092519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546773113 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | SW4129 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | SW4129 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 752005100 | 05 | FL | MEDICAID |