Provider Demographics
NPI:1871061754
Name:THOMAS, ANTAYSIA (LCSW)
Entity type:Individual
Prefix:MS
First Name:ANTAYSIA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANTAYSIA
Other - Middle Name:
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:10908 COURTHOUSE RD STE 102149
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-2658
Mailing Address - Country:US
Mailing Address - Phone:540-210-7624
Mailing Address - Fax:
Practice Address - Street 1:307 LAFAYETTE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-6066
Practice Address - Country:US
Practice Address - Phone:540-840-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040106711041C0700X
VA090401106711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30016769040004Medicaid