1104930106 NPI number — BEN A THOMAS MSSW LCSW

Table of content: BEN A THOMAS MSSW LCSW (NPI 1104930106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104930106 NPI number — BEN A THOMAS MSSW LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
BEN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSSW LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104930106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 MULBERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47713-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-423-7791
Provider Business Mailing Address Fax Number:
812-422-7558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 S 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47670-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-385-5275
Provider Business Practice Location Address Fax Number:
812-422-7558
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34000308A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11491045 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100240880 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000176991 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 839090R . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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