Provider Demographics
NPI:1962240697
Name:THOMAS, MARIAH NICOLE
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:NICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BAYONET ST STE 207
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2600
Mailing Address - Country:US
Mailing Address - Phone:959-213-6234
Mailing Address - Fax:
Practice Address - Street 1:400 BAYONET ST STE 207
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2600
Practice Address - Country:US
Practice Address - Phone:959-213-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health