Provider Demographics
NPI:1821212903
Name:CROSS, THOMAS EDWARD (LICSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:CROSS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 COON RAPIDS BLVD NW
Mailing Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4708
Mailing Address - Country:US
Mailing Address - Phone:763-427-7964
Mailing Address - Fax:763-427-7976
Practice Address - Street 1:1930 COON RAPIDS BLVD NW
Practice Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4708
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP39507OtherHEALTH PARTNERS
ND947D5CROtherBCBSMN
MN110613OtherUCARE
MN202857300Medicaid
MN39507OtherHEALTH PARTNERS
MN6C682CROtherBCBS
MN1040047OtherPREFERRED ONE
ND28033OtherBCBSND
MN1821212903OtherUBH