Basic Information
| Provider Information | |||||||||
| NPI: | 1952634420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | SHELISSA | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | CDC1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82321 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997082321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074572176 | ||||||||
| FaxNumber: | 9074572196 | ||||||||
| Practice Location | |||||||||
| Address1: | 542 4TH AVE STE B101 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073741097 | ||||||||
| FaxNumber: | 9074572196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2009 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | AK | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | 3185 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 251C00000X | 05 | AK | MEDICAID | 251C00000X | 01 | AK | CARE COORDINATOR ADMINISTRATOR | OTHER | 3185 | 01 | AK | ADDICTION COUNSELOR | OTHER |