Provider Demographics
NPI:1447420641
Name:BECKER, THOMAS C (CERTIFIED SUBSTANCE)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:C
Last Name:BECKER
Suffix:
Gender:M
Credentials:CERTIFIED SUBSTANCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901
Mailing Address - Country:US
Mailing Address - Phone:920-231-0143
Mailing Address - Fax:920-231-4246
Practice Address - Street 1:3240 JACKSON ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901
Practice Address - Country:US
Practice Address - Phone:920-231-0143
Practice Address - Fax:920-231-4246
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI874132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39318600Medicaid