Provider Demographics
NPI:1154564185
Name:AYALA, THOMAS WESLEY (LICENSED COUNSELOR)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WESLEY
Last Name:AYALA
Suffix:
Gender:M
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-0280
Mailing Address - Country:US
Mailing Address - Phone:541-258-8210
Mailing Address - Fax:541-258-8212
Practice Address - Street 1:880 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355
Practice Address - Country:US
Practice Address - Phone:541-258-8210
Practice Address - Fax:541-258-8212
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1962101YP2500X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC227513OtherNATIONAL BOARD CERTIFIED COUNSELOR
ORC1962OtherLICENSED PROFESSIONAL COUNSELOR