Provider Demographics
NPI:1164524781
Name:DOUST, THOMAS J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:DOUST
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3154 MALLARD COVE LANE
Mailing Address - Street 2:
Mailing Address - City:FT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-432-2489
Mailing Address - Fax:260-432-8236
Practice Address - Street 1:3154 MALLARD COVE LANE
Practice Address - Street 2:
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-432-2489
Practice Address - Fax:260-432-8236
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000699A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN182580Medicare ID - Type Unspecified