Provider Demographics
NPI:1780375386
Name:FORNEA, THOMAS R (CPP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:FORNEA
Suffix:
Gender:M
Credentials:CPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 MEMPHIS ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3844
Mailing Address - Country:US
Mailing Address - Phone:985-735-0160
Mailing Address - Fax:
Practice Address - Street 1:216 MEMPHIS ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3844
Practice Address - Country:US
Practice Address - Phone:985-735-0160
Practice Address - Fax:985-735-0970
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACPP-5001405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional