Provider Demographics
NPI:1063410900
Name:THOMAS, ANTOINETTE R (PHD)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:R
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 EMMET STREET, SOUTH
Mailing Address - Street 2:P.O. BOX 400270
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22904-4270
Mailing Address - Country:US
Mailing Address - Phone:434-924-7034
Mailing Address - Fax:434-924-4621
Practice Address - Street 1:417 EMMET STREET, SOUTH
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22904-4270
Practice Address - Country:US
Practice Address - Phone:434-924-7034
Practice Address - Fax:434-924-4621
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002643103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007710798Medicaid
VA000970R01Medicare PIN