Provider Demographics
NPI:1346260072
Name:SUPAN, THOMAS J (LPCC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:SUPAN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12300 MCCRACKEN RD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2914
Mailing Address - Country:US
Mailing Address - Phone:216-587-8350
Mailing Address - Fax:216-587-8646
Practice Address - Street 1:12300 MCCRACKEN RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2914
Practice Address - Country:US
Practice Address - Phone:216-587-8350
Practice Address - Fax:216-587-8646
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-988101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH741000OtherBUCKEYE HEALTH PLAN
OH7745428OtherAETNA
OH353306OtherWELLCARE HEALTH PLAN
OHT00988OtherSUMMACARE HEALTH PLAN
OH000000216098OtherANTHEM BLUE CROSS PIN
OH000000216098OtherUNICARE