Provider Demographics
NPI:1871847483
Name:DOCTOR, THOMAS S (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:DOCTOR
Suffix:
Gender:M
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 W MONTROSE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1562
Mailing Address - Country:US
Mailing Address - Phone:773-377-5261
Mailing Address - Fax:
Practice Address - Street 1:2650 W MONTROSE AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1562
Practice Address - Country:US
Practice Address - Phone:773-377-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-04
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490203861041C0700X
IL101YM0800X
IL150.102002104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health