Provider Demographics
NPI:1447352067
Name:THOMAS, TIA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 W 200 N
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5405
Mailing Address - Country:US
Mailing Address - Phone:208-317-6318
Mailing Address - Fax:208-782-1074
Practice Address - Street 1:34 LOUELLA ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1609
Practice Address - Country:US
Practice Address - Phone:208-317-6318
Practice Address - Fax:208-782-1074
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW25452104100000X
IDLCSW-25452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker