Healthcare Provider Details

I. General information

NPI: 1366655219
Provider Name (Legal Business Name): SEAN WILLIAM THOM B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 E 46TH ST SUITE J
INDIANAPOLIS IN
46205-2380
US

IV. Provider business mailing address

19466 GOLDEN MEADOW WAY
NOBLESVILLE IN
46060-7593
US

V. Phone/Fax

Practice location:
  • Phone: 317-475-9066
  • Fax: 317-257-3602
Mailing address:
  • Phone: 317-776-2751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: