Provider Demographics
NPI:1336366517
Name:THOMAS, ELTON DESMOND
Entity type:Individual
Prefix:MR
First Name:ELTON
Middle Name:DESMOND
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 RIVERGATE WAY APT 141
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3320
Mailing Address - Country:US
Mailing Address - Phone:916-395-7748
Mailing Address - Fax:
Practice Address - Street 1:2801 ARAMON DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-4803
Practice Address - Country:US
Practice Address - Phone:916-361-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB6799486OtherDRIVERS LICENSE