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
StateLicense IDTaxonomies
MN140611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN090H8WAOtherBLUE CROSS BLUE SHIELD OF MINNESOTA CLINIC ID
MN090H8WAOtherBLUE CROSS BLUE SHIELD OF MINNESOTA PROVIDER ID
MN444260100Medicaid