Provider Demographics
NPI:1558430769
Name:DANIEL, THOMAS (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DANIEL
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HIGHWAY 25 N
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2930
Mailing Address - Country:US
Mailing Address - Phone:763-682-2011
Mailing Address - Fax:763-682-2165
Practice Address - Street 1:1200 HIGHWAY 25 N
Practice Address - Street 2:SUITE 108
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2930
Practice Address - Country:US
Practice Address - Phone:763-682-2011
Practice Address - Fax:763-682-2165
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11618103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN330445100Medicaid