Provider Demographics
NPI:1730207747
Name:THOMAS, FREDA SHAVON (LCSW)
Entity type:Individual
Prefix:MS
First Name:FREDA
Middle Name:SHAVON
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 PLAZA DR STE F
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1667
Mailing Address - Country:US
Mailing Address - Phone:903-701-6789
Mailing Address - Fax:
Practice Address - Street 1:5411 PLAZA DR STE F
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1667
Practice Address - Country:US
Practice Address - Phone:903-701-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2608-C1041C0700X
TX220041067171M00000X
TX543281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR9037016789Medicare PIN
TXTXB136232Medicare PIN