=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255431003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS EUGENE WILLIAMS MSW LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7400 METRO BLVD STE 211
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-2321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-835-1616
-----------------------------------------------------
Fax | 833-895-1211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1880 CHRISTY DR
-----------------------------------------------------
City | CARVER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55315-4592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 592-705-6895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 15398
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------