Provider Demographics
NPI: | 1245491877 |
---|---|
Name: | WALES, THOMAS GWYNNE (MSW LICSW) |
Entity type: | Individual |
Prefix: | MR |
First Name: | THOMAS |
Middle Name: | GWYNNE |
Last Name: | WALES |
Suffix: | |
Gender: | M |
Credentials: | MSW LICSW |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 627 SNELLING AVE. S |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | ST. PAUL |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55116 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 651-699-1062 |
Mailing Address - Fax: | 651-699-1084 |
Practice Address - Street 1: | 627 SNELLING AVE S |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | SAINT PAUL |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55116-1590 |
Practice Address - Country: | US |
Practice Address - Phone: | 651-699-1062 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2008-06-17 |
Last Update Date: | 2013-06-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 14061 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 090H8WA | Other | BLUE CROSS BLUE SHIELD OF MINNESOTA CLINIC ID |
MN | 090H8WA | Other | BLUE CROSS BLUE SHIELD OF MINNESOTA PROVIDER ID |
MN | 444260100 | Medicaid |