Provider Demographics
NPI:1982334249
Name:THOMAS, JUANITA LEE
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:LEE
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 1:6924 S 74TH LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-5093
Mailing Address - Country:US
Mailing Address - Phone:602-595-6585
Mailing Address - Fax:
Practice Address - Street 1:6924 S 74TH LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-5093
Practice Address - Country:US
Practice Address - Phone:602-595-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5299458253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency