1447459482 NPI number — DR. THOMAS JEFFERSON POUNDERS III LCSW, MDIV, PHD

Table of content: DR. THOMAS JEFFERSON POUNDERS III LCSW, MDIV, PHD (NPI 1447459482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447459482 NPI number — DR. THOMAS JEFFERSON POUNDERS III LCSW, MDIV, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POUNDERS
Provider First Name:
THOMAS
Provider Middle Name:
JEFFERSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
LCSW, MDIV, PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POUNDERS
Provider Other First Name:
JEFF
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1447459482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4421 W OKMULGEE ST # 328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSKOGEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74401-4651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-320-5287
Provider Business Mailing Address Fax Number:
918-577-3701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 HONOR HEIGHTS DR
Provider Second Line Business Practice Location Address:
MAIL CODE 115
Provider Business Practice Location Address City Name:
MUSKOGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74401-1318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-577-3000
Provider Business Practice Location Address Fax Number:
918-577-3648
Provider Enumeration Date:
07/11/2007

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: 104100000X , with the licence number:  LCSW 3620 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LCSW 3620 . This is a "OKLAHOMA STATE BOARD OF LICENSED SOCIAL WORKERS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: CERT CASE MGR 9983 . This is a "OKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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