Provider Demographics
NPI:1194932764
Name:BETTIS, THOMAS A JR (LSCSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:BETTIS
Suffix:JR
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 W 94TH TER
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2502
Mailing Address - Country:US
Mailing Address - Phone:913-649-5567
Mailing Address - Fax:913-649-7563
Practice Address - Street 1:5200 W 94TH TER
Practice Address - Street 2:SUITE 105
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207-2502
Practice Address - Country:US
Practice Address - Phone:913-649-5567
Practice Address - Fax:913-649-7563
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS27178201OtherBCBS
KS0002535AMedicare UPIN