Provider Demographics
NPI:1124245576
Name:VANFOSSEN, THOMAS R (LMFT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:VANFOSSEN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5431 N GOVERNMENT WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-5073
Mailing Address - Country:US
Mailing Address - Phone:208-667-7603
Mailing Address - Fax:208-667-7609
Practice Address - Street 1:5431 N GOVERNMENT WAY
Practice Address - Street 2:SUITE B
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5073
Practice Address - Country:US
Practice Address - Phone:208-667-7603
Practice Address - Fax:208-667-7609
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT3019106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist