Provider Demographics
NPI:1194879536
Name:WAITE, THOMAS MICHAEL (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:WAITE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CASTLE COURT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-335-9239
Mailing Address - Fax:
Practice Address - Street 1:102 CASTLE COURT
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-335-9239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0036271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003559Medicaid
NC1278COtherBLUE CROSS-BLUE SHEILD
NC6003559Medicaid