Provider Demographics
NPI:1912982893
Name:THOM, KENNETH T (LPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:T
Last Name:THOM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W COOPER ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2417
Mailing Address - Country:US
Mailing Address - Phone:660-562-2531
Mailing Address - Fax:660-562-3239
Practice Address - Street 1:515 W COOPER ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2417
Practice Address - Country:US
Practice Address - Phone:660-562-2531
Practice Address - Fax:660-562-3239
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10001042101Medicare UPIN
MO24206013Medicare UPIN