Basic Information
| Provider Information | |||||||||
| NPI: | 1801066345 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THOMAS J. CLUCAS, PHD, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BANK ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 BANK ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLUCAS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4065497325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 186 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1083763643 | 05 | MT | MEDICAID | 51981 | 01 | MT | BLUE CROSS BLUE SHIELD | OTHER |