Provider Demographics
NPI:1144754029
Name:FOSSEDAL, THOMAS A (BA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:FOSSEDAL
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:A
Other - Last Name:FOSSEDAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:7727 46TH PL W
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-2703
Mailing Address - Country:US
Mailing Address - Phone:425-218-9771
Mailing Address - Fax:
Practice Address - Street 1:7727 46TH PL W
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-2703
Practice Address - Country:US
Practice Address - Phone:425-218-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health