Provider Demographics
NPI:1043729551
Name:THOMAS, CLARENCE VERN
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:VERN
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514-0041
Mailing Address - Country:US
Mailing Address - Phone:307-349-2243
Mailing Address - Fax:
Practice Address - Street 1:24 GREAT PLAINS ROAD
Practice Address - Street 2:
Practice Address - City:ARAPAHOE
Practice Address - State:WY
Practice Address - Zip Code:82510-0024
Practice Address - Country:US
Practice Address - Phone:307-856-0470
Practice Address - Fax:307-857-4383
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)