Provider Demographics
NPI:1699524702
Name:LEFTWICH, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LEFTWICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 N LAKEHARBOR LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-6913
Mailing Address - Country:US
Mailing Address - Phone:208-991-4296
Mailing Address - Fax:
Practice Address - Street 1:1799 N LAKES PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1833
Practice Address - Country:US
Practice Address - Phone:208-888-5905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-10301101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional