Provider Demographics
NPI:1861795650
Name:LABOMBARD, THOMAS KELLY (LICSW)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:KELLY
Last Name:LABOMBARD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:TATUM
Other - Middle Name:COUNSELING
Other - Last Name:SERVICES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8618 DICKEY RD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9214
Mailing Address - Country:US
Mailing Address - Phone:360-434-3699
Mailing Address - Fax:888-975-7504
Practice Address - Street 1:9395 LINDER WAY NW
Practice Address - Street 2:SUITE 202
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9149
Practice Address - Country:US
Practice Address - Phone:360-434-3699
Practice Address - Fax:888-975-7504
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 602246391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical