Healthcare Provider Details

I. General information

NPI: 1184482929
Provider Name (Legal Business Name): ANGELA DAWN THOMAS MA, LPCC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 S POKEGAMA AVE
GRAND RAPIDS MN
55744-3820
US

IV. Provider business mailing address

505 SE 21ST ST APT 305
GRAND RAPIDS MN
55744-2368
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-2001
  • Fax:
Mailing address:
  • Phone: 218-910-8147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC04277
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC04277
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305922
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: