Provider Demographics
NPI:1588716138
Name:THOMAS, LISETTA FLORENCE (LPC)
Entity type:Individual
Prefix:MS
First Name:LISETTA
Middle Name:FLORENCE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 HUNTING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-5544
Mailing Address - Country:US
Mailing Address - Phone:817-568-1419
Mailing Address - Fax:
Practice Address - Street 1:501 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2270
Practice Address - Country:US
Practice Address - Phone:917-817-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X
TXNA101YS0200X
TX18376101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNAOtherSCHOOL COUNSELOR
TX42-1648622OtherFED TAX ID
TX18376OtherLPC
TX66915OtherNCC