Provider Demographics
NPI:1730703497
Name:TICUM, THOMSON
Entity type:Individual
Prefix:
First Name:THOMSON
Middle Name:
Last Name:TICUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13033 BOND ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-4464
Mailing Address - Country:US
Mailing Address - Phone:316-925-3943
Mailing Address - Fax:
Practice Address - Street 1:8645 COLLEGE BLVD STE 125
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2034
Practice Address - Country:US
Practice Address - Phone:316-925-3943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional