=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104918093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. THOMAS MANVILLE REFF
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 02/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 S MINNESOTA ST
-----------------------------------------------------
City | CROOKSTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56716-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-281-9514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 SOUTH MN ST
-----------------------------------------------------
City | CROOKSTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-281-9514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 302002
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 17830
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------