Provider Demographics
NPI:1366288532
Name:SHEA, THOMAS (CIT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SHEA
Suffix:
Gender:M
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10502 N MYRTLELAKE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-6638
Mailing Address - Country:US
Mailing Address - Phone:808-222-9445
Mailing Address - Fax:
Practice Address - Street 1:5311 DIJON DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4314
Practice Address - Country:US
Practice Address - Phone:225-300-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5552101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)