Provider Demographics
NPI:1891006177
Name:MAGNAN, THOMAS EDWARD (LADCI)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EDWARD
Last Name:MAGNAN
Suffix:
Gender:M
Credentials:LADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 L ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1511
Mailing Address - Country:US
Mailing Address - Phone:617-268-5000
Mailing Address - Fax:617-268-5008
Practice Address - Street 1:49 L ST
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1511
Practice Address - Country:US
Practice Address - Phone:617-268-5000
Practice Address - Fax:617-268-5008
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1369101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1369OtherLADCI