Provider Demographics
NPI:1316953037
Name:THOMAS, IDA S (LCSW)
Entity type:Individual
Prefix:MS
First Name:IDA
Middle Name:S
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 1:7063 BRYCE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1953
Mailing Address - Country:US
Mailing Address - Phone:404-730-0230
Mailing Address - Fax:404-730-0341
Practice Address - Street 1:265 BOULEVARD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1208
Practice Address - Country:US
Practice Address - Phone:404-730-1650
Practice Address - Fax:404-730-1651
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0031141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical