Basic Information
| Provider Information | |||||||||
| NPI: | 1487010732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | CRISTY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RADT-1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 871 | ||||||||
| Address2: | |||||||||
| City: | GARDEN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956330871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303339460 | ||||||||
| FaxNumber: | 5303331019 | ||||||||
| Practice Location | |||||||||
| Address1: | 5607 MOUNT MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | GARDEN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956330871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303339460 | ||||||||
| FaxNumber: | 5303331019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2015 | ||||||||
| LastUpdateDate: | 12/31/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R97341214 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.