Provider Demographics
NPI:1013287507
Name:THOMAS, SHAD M (LCSW, MSW, CADC III)
Entity Type:Individual
Prefix:
First Name:SHAD
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LCSW, MSW, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 138
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-0138
Mailing Address - Country:US
Mailing Address - Phone:541-573-7303
Mailing Address - Fax:541-573-5938
Practice Address - Street 1:2200 4TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-2615
Practice Address - Country:US
Practice Address - Phone:541-573-7303
Practice Address - Fax:541-573-5938
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-01-16101YA0400X
ORL69151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR090450Medicaid
OR500666423OtherMCD
OR090450Medicaid