Provider Demographics
NPI:1093925554
Name:RANCOUR, THOM JOSEPH (LMSW)
Entity Type:Individual
Prefix:MR
First Name:THOM
Middle Name:JOSEPH
Last Name:RANCOUR
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 BEDELL AVE
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49968-1511
Mailing Address - Country:US
Mailing Address - Phone:906-224-1399
Mailing Address - Fax:
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:906-229-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010714841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801071484OtherCLINICAL SOCIAL WORKER