Provider Demographics
NPI:1467501031
Name:THOMAS, KATHERINE K (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:K
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 INWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6625
Mailing Address - Country:US
Mailing Address - Phone:651-592-5197
Mailing Address - Fax:651-344-0857
Practice Address - Street 1:980 INWOOD AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6625
Practice Address - Country:US
Practice Address - Phone:651-592-5197
Practice Address - Fax:651-344-0857
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4488103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN403028100Medicaid
MN680001942Medicare ID - Type Unspecified