Provider Demographics
NPI:1063738359
Name:THOMSON, GLENDA K (LCSW)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:K
Last Name:THOMSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 E 25TH ST
Mailing Address - Street 2:SUITE 290
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7519
Mailing Address - Country:US
Mailing Address - Phone:208-552-0490
Mailing Address - Fax:208-552-2518
Practice Address - Street 1:2235 E 25TH ST
Practice Address - Street 2:SUITE 290
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7519
Practice Address - Country:US
Practice Address - Phone:208-552-0490
Practice Address - Fax:208-552-2518
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-215291041C0700X
IDLCSW301861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806472900Medicaid