Healthcare Provider Details

I. General information

NPI: 1164684817
Provider Name (Legal Business Name): ERIC THOMAS CUESTAS-THOMPSON LICSW, LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 MARKET ST STE 80
TACOMA WA
98402-3737
US

IV. Provider business mailing address

748 MARKET ST # 80
TACOMA WA
98402-3737
US

V. Phone/Fax

Practice location:
  • Phone: 520-272-4650
  • Fax: 253-697-9938
Mailing address:
  • Phone: 520-272-4650
  • Fax: 253-697-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10713
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-12502
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60509544
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: