Provider Demographics
NPI:1144661729
Name:THOMAS, SCOTT WILLIAM
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6369 S 86TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1356
Mailing Address - Country:US
Mailing Address - Phone:918-991-5771
Mailing Address - Fax:
Practice Address - Street 1:1814 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6503
Practice Address - Country:US
Practice Address - Phone:918-991-5771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
OK1492101YP2500X
OK722106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK722OtherOKLAHOMA STATE DEPARTMENT OF HEALTH/LMFT LICENSE
OK1492OtherOKLAHOMA STATE DEPARTMENT OF HEALTH/LPC LICENSE