Provider Demographics
NPI:1194942185
Name:TOMAZIN, KATHLEEN S (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:S
Last Name:TOMAZIN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 W JUDICIAL ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2715
Mailing Address - Country:US
Mailing Address - Phone:208-782-2060
Mailing Address - Fax:208-782-0209
Practice Address - Street 1:90 W JUDICIAL ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2715
Practice Address - Country:US
Practice Address - Phone:208-782-2060
Practice Address - Fax:208-782-0209
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 332101YP2500X
IDLSW 1810104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80662262Medicaid
ID8059327Medicaid