Provider Demographics
NPI:1457510950
Name:CONCANNON, THOMAS D (LMFT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:CONCANNON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2631
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-2631
Mailing Address - Country:US
Mailing Address - Phone:307-733-6440
Mailing Address - Fax:307-733-6374
Practice Address - Street 1:510 S CACHE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-6440
Practice Address - Fax:307-733-6374
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT 127106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist