Provider Demographics
NPI:1063534469
Name:THOMAS WALES, MSW, LICSW
Entity type:Organization
Organization Name:THOMAS WALES, MSW, LICSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GWYNNE
Authorized Official - Last Name:WALES
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:651-699-1062
Mailing Address - Street 1:627 SNELLING AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1590
Mailing Address - Country:US
Mailing Address - Phone:651-699-1062
Mailing Address - Fax:651-699-1084
Practice Address - Street 1:627 SNELLING AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1590
Practice Address - Country:US
Practice Address - Phone:651-699-1062
Practice Address - Fax:651-699-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN140611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4442601-00Medicaid
MN090H8WAOtherBLUE CROSS BLUE SHIELD MN