Healthcare Provider Details

I. General information

NPI: 1417367962
Provider Name (Legal Business Name): DR TOM CONBOY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 14TH ST SUITE A
PHENIX CITY AL
36867-4907
US

IV. Provider business mailing address

1200 14TH ST SUITE A
PHENIX CITY AL
36867-4907
US

V. Phone/Fax

Practice location:
  • Phone: 205-821-1607
  • Fax:
Mailing address:
  • Phone: 205-821-1607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number555
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number555
License Number StateAL

VIII. Authorized Official

Name: DR. THOMAS JOSEPH CONBOY
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 205-821-1607