Provider Demographics
NPI:1871614412
Name:THOMAS, GARY (MS)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-2315
Mailing Address - Country:US
Mailing Address - Phone:541-215-1963
Mailing Address - Fax:
Practice Address - Street 1:73265 CONFEDERATED WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-9099
Practice Address - Country:US
Practice Address - Phone:541-215-1963
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR126370Medicaid
OR0000WCQLVMedicare ID - Type Unspecified