Provider Demographics
NPI:1700276060
Name:GAFFNEY, THOMAS (RN, C LPC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GAFFNEY
Suffix:
Gender:M
Credentials:RN, C LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3982
Mailing Address - Country:US
Mailing Address - Phone:218-327-6139
Mailing Address - Fax:218-327-5535
Practice Address - Street 1:1209 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3982
Practice Address - Country:US
Practice Address - Phone:218-327-6139
Practice Address - Fax:218-327-6139
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3455-125101YP2500X
MNR 89695-5163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional