1821212903 NPI number — THOMAS EDWARD CROSS LICSW

Table of content: (NPI 1942571286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821212903 NPI number — THOMAS EDWARD CROSS LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSS
Provider First Name:
THOMAS
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
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:
1821212903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 COON RAPIDS BLVD NW
Provider Second Line Business Mailing Address:
FAMILY LIFE MENTAL HEALTH CENTER
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-4708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-427-7964
Provider Business Mailing Address Fax Number:
763-427-7976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 COON RAPIDS BLVD NW
Provider Second Line Business Practice Location Address:
FAMILY LIFE MENTAL HEALTH CENTER
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-4708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-427-7964
Provider Business Practice Location Address Fax Number:
763-427-7976
Provider Enumeration Date:
04/12/2007

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: 1041C0700X , with the licence number:  1358 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HP39507 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 947D5CR . This is a "BCBSMN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 110613 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 202857300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39507 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6C682CR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1040047 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 28033 . This is a "BCBSND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1821212903 . This is a "UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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