Healthcare Provider Details

I. General information

NPI: 1497818835
Provider Name (Legal Business Name): MR. RYAN B THOMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W PARK AVE
CHAMPAIGN IL
61820-3929
US

IV. Provider business mailing address

1607 VALLEY RD APT D1
CHAMPAIGN IL
61820-7122
US

V. Phone/Fax

Practice location:
  • Phone: 217-373-2428
  • Fax:
Mailing address:
  • Phone: 217-356-3461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: