Healthcare Provider Details

I. General information

NPI: 1194786749
Provider Name (Legal Business Name): LINDA M THOMAS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3314 33RD ST SW
FARGO ND
58104-5158
US

IV. Provider business mailing address

PO BOX 1148
MINOT ND
58702-1148
US

V. Phone/Fax

Practice location:
  • Phone: 701-837-6508
  • Fax: 701-858-1839
Mailing address:
  • Phone: 701-837-6508
  • Fax: 701-858-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number743
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier19148
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier26470
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBLUE CROSS BLUE SHIELD ND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: