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General NPI Number Information
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NPI Number | 1730496035
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Entity Type | Organization
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Legal Business Name | THOMAS R VAN FOSSEN
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Dates
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Enumeration Date | 09/08/2010
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Last Update Date | 11/10/2010
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Provider Practice Location Address
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Address Line | 5431 N GOVERNMENT WAY # B
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City | COEUR D ALENE
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State | ID
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Zip | 83815-5073
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Country | US
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Telephone | 208-667-7603
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Fax | 208-667-7609
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Provider Business Mailing Address
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Address Line | 5431 N GOVERNMENT WAY # B
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City | COEUR D ALENE
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State | ID
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Zip | 83815-5073
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Country | US
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Telephone | 208-667-7603
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Fax | 208-667-7609
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Authorized Official
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Title or Position | OWNER
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Name | MR. THOMAS R VAN FOSSEN
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Credential | M.ED,MS,LMFT
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Telephone | 208-667-7603
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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