Provider Demographics
NPI:1194151290
Name:POUGH, THOMAS (MS, LPC, CSAT)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:POUGH
Suffix:
Gender:M
Credentials:MS, LPC, CSAT
Other - Prefix:MR
Other - First Name:ODIS
Other - Middle Name:D
Other - Last Name:POUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAA
Mailing Address - Street 1:39 BETHANY LN
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:MS
Mailing Address - Zip Code:39643-4996
Mailing Address - Country:US
Mailing Address - Phone:601-466-2375
Mailing Address - Fax:601-736-0287
Practice Address - Street 1:806 W PINE ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4259
Practice Address - Country:US
Practice Address - Phone:601-466-2375
Practice Address - Fax:601-736-0287
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1365101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional