Healthcare Provider Details

I. General information

NPI: 1295910602
Provider Name (Legal Business Name): THOMAS FLETCHER THORNTON LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601-A ST. MICHAEL'S DR.
SANTA FE NM
87505-1601
US

IV. Provider business mailing address

P.O. BOX 2062
LAS VEGAS NM
87701-2062
US

V. Phone/Fax

Practice location:
  • Phone: 509-429-1462
  • Fax:
Mailing address:
  • Phone: 505-429-1462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-1512
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: