Provider Demographics
NPI:1699013094
Name:CORPORON, THOMAS R (MS, PLPC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:CORPORON
Suffix:
Gender:M
Credentials:MS, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:64067-1364
Mailing Address - Country:US
Mailing Address - Phone:660-259-3900
Mailing Address - Fax:660-259-9127
Practice Address - Street 1:109 S 10TH ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067-1364
Practice Address - Country:US
Practice Address - Phone:660-259-3900
Practice Address - Fax:660-259-9127
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013000675101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional