Provider Demographics
NPI:1407234073
Name:KNUDSEN, TOM EDMUND
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:EDMUND
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:EDMUND
Other - Last Name:KNUDSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:923 NE 18TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-8203
Mailing Address - Country:US
Mailing Address - Phone:405-973-6135
Mailing Address - Fax:
Practice Address - Street 1:923 NE 18TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-8203
Practice Address - Country:US
Practice Address - Phone:405-973-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker