Provider Demographics
NPI:1154868347
Name:THAYER, JAMES (CP00004542)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:THAYER
Suffix:
Gender:M
Credentials:CP00004542
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 14TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:2700 SIMPSON AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-612-0012
Practice Address - Fax:360-218-5945
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004542101YA0400X
WA00004542101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health