Healthcare Provider Details

I. General information

NPI: 1194932764
Provider Name (Legal Business Name): THOMAS A BETTIS JR. LSCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 W 94TH TER SUITE 105
PRAIRIE VILLAGE KS
66207-2502
US

IV. Provider business mailing address

5200 W 94TH TER SUITE 105
PRAIRIE VILLAGE KS
66207-2502
US

V. Phone/Fax

Practice location:
  • Phone: 913-649-5567
  • Fax: 913-649-7563
Mailing address:
  • Phone: 913-649-5567
  • Fax: 913-649-7563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1373
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: