Healthcare Provider Details

I. General information

NPI: 1326591116
Provider Name (Legal Business Name): THOMAS BRINKLEY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 E 14 N
AMMON ID
83401-2301
US

IV. Provider business mailing address

1259 N 1120 E
SHELLEY ID
83274-5170
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-1222
  • Fax:
Mailing address:
  • Phone: 208-200-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number35997
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: