Provider Demographics
NPI:1174188775
Name:THOMAS, SHAVONE
Entity type:Individual
Prefix:
First Name:SHAVONE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 SIMMONS ST APT 2127
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1560
Mailing Address - Country:US
Mailing Address - Phone:702-712-2593
Mailing Address - Fax:
Practice Address - Street 1:4955 S DURANGO DR STE 124
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-1054
Practice Address - Country:US
Practice Address - Phone:702-871-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2022-09-07
Deactivation Date:2020-02-25
Deactivation Code:
Reactivation Date:2022-09-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1234567OtherN/A
NV123456OtherN/A