Basic Information
| Provider Information | |||||||||
| NPI: | 1629423470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED RASAC II MARS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1513 JEFFERSON ROAD | ||||||||
| Address2: | |||||||||
| City: | BOONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738360076 | ||||||||
| FaxNumber: | 5734498344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 JEFFERSON RD | ||||||||
| Address2: | |||||||||
| City: | BOONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652332271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738360076 | ||||||||
| FaxNumber: | 5734498344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2016 | ||||||||
| LastUpdateDate: | 04/29/2016 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.