Basic Information
| Provider Information | |||||||||
| NPI: | 1831426501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | GENEVIEVE | ||||||||
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| Credential: | LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 SARTIN DR | ||||||||
| Address2: | |||||||||
| City: | EDMONTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421298170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704324951 | ||||||||
| FaxNumber: | 2704325054 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 SARTIN DR | ||||||||
| Address2: | |||||||||
| City: | EDMONTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421298170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704324951 | ||||||||
| FaxNumber: | 2704325054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2009 | ||||||||
| LastUpdateDate: | 11/17/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | KY-0951 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 30604011 | 05 | KY | MEDICAID |