Provider Demographics
NPI:1518708171
Name:THOMAS, VICTOR KIERNAN
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:KIERNAN
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 1:4650 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2376
Mailing Address - Country:US
Mailing Address - Phone:208-648-4167
Mailing Address - Fax:
Practice Address - Street 1:4650 HAWTHORNE RD STE 3B
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2376
Practice Address - Country:US
Practice Address - Phone:208-648-4167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health