Provider Demographics
NPI:1790299295
Name:THOMAS, SHATORIA TYSHON (LCMHCA, LCASA)
Entity type:Individual
Prefix:
First Name:SHATORIA
Middle Name:TYSHON
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCMHCA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1002
Mailing Address - Country:US
Mailing Address - Phone:704-376-7447
Mailing Address - Fax:
Practice Address - Street 1:429 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1007
Practice Address - Country:US
Practice Address - Phone:704-445-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22433101YA0400X
NCA13369101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health