Provider Demographics
NPI:1871160002
Name:THOMAS, COURTLYN LEE (LBA)
Entity type:Individual
Prefix:MS
First Name:COURTLYN
Middle Name:LEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 PENNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-3810
Mailing Address - Country:US
Mailing Address - Phone:610-529-1927
Mailing Address - Fax:
Practice Address - Street 1:522 S INDEPENDENCE BLVD STE 102D
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1149
Practice Address - Country:US
Practice Address - Phone:610-529-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001968103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst