Provider Demographics
NPI:1215757869
Name:HAUGUM, THOMAS JERAD (SUDCC III)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JERAD
Last Name:HAUGUM
Suffix:
Gender:M
Credentials:SUDCC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 FIFTH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5773
Mailing Address - Country:US
Mailing Address - Phone:907-463-0629
Mailing Address - Fax:
Practice Address - Street 1:3050 FIFTH AVE STE 100
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5773
Practice Address - Country:US
Practice Address - Phone:907-463-0629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9184101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)