MEDICARE: MR. CLARENCE VERN THOMAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		WY

General Provider Information

NPI Number	:	1043729551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLARENCE VERN THOMAS

Provider Business Mailing Address
First Line	:	PO BOX 41
Second Line	:
City	:	FORT WASHAKIE
State	:	WY
Zip	:	82514-0041
Country	:	US
Telephone Number	:	307-349-2243
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 GREAT PLAINS ROAD
Second Line	:
City	:	ARAPAHOE
State	:	WY
Zip	:	82510-0024
Country	:	US
Telephone Number	:	307-856-0470
Fax Number	:	307-857-4383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2017
Last Update Date	:	09/27/2017

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Directions to “ MR. CLARENCE VERN THOMAS ” Practice Location

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