Provider Demographics
NPI:1386703106
Name:AMAYA, THOMAS JOHN SR (LCPC, LAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:AMAYA
Suffix:SR
Gender:M
Credentials:LCPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 S HARDY DR APT 2121
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-6569
Mailing Address - Country:US
Mailing Address - Phone:406-239-8749
Mailing Address - Fax:480-768-2053
Practice Address - Street 1:9405 S AVENIDA DEL YAQUI
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2529
Practice Address - Country:US
Practice Address - Phone:480-768-2000
Practice Address - Fax:480-768-2053
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT778101Y00000X
MT1101101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0256989Medicaid
MT1101OtherLICENSE FOR LAC
MT778OtherLICENSE FOR LCPC