Provider Demographics
NPI:1255845301
Name:VANCURA, THOMAS (LICSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:VANCURA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 HEWITT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1424
Mailing Address - Country:US
Mailing Address - Phone:651-206-1979
Mailing Address - Fax:
Practice Address - Street 1:14955 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4519
Practice Address - Country:US
Practice Address - Phone:952-891-7468
Practice Address - Fax:952-891-7335
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN194131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical