Provider Demographics
NPI:1245513548
Name:SOULE, THOMAS GILLETTE (LCSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GILLETTE
Last Name:SOULE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EDGERTON PARK
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1054
Mailing Address - Country:US
Mailing Address - Phone:585-787-0963
Mailing Address - Fax:
Practice Address - Street 1:1 EDGERTON PARK
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-1054
Practice Address - Country:US
Practice Address - Phone:585-787-0963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP044396-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP044396-1Medicaid