Provider Demographics
NPI:1285955997
Name:THOMAS, ANDERSON (LPCC)
Entity type:Individual
Prefix:
First Name:ANDERSON
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 07 BIA 140
Mailing Address - Street 2:
Mailing Address - City:PINE HILL
Mailing Address - State:NM
Mailing Address - Zip Code:87357
Mailing Address - Country:US
Mailing Address - Phone:505-775-3353
Mailing Address - Fax:505-775-3630
Practice Address - Street 1:15 BEHAVIORAL HEALTH ROAD
Practice Address - Street 2:
Practice Address - City:PINE HILL
Practice Address - State:NM
Practice Address - Zip Code:87357-0004
Practice Address - Country:US
Practice Address - Phone:505-775-3353
Practice Address - Fax:505-775-3630
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0132611101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0005587Medicaid