Healthcare Provider Details

I. General information

NPI: 1225206584
Provider Name (Legal Business Name): THOMAS E HOLSWORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 MANNHEIM RD SUITE G
JASPER IN
47546-9617
US

IV. Provider business mailing address

4201 MANNHEIM RD SUITE G
JASPER IN
47546-9617
US

V. Phone/Fax

Practice location:
  • Phone: 812-481-9988
  • Fax: 812-481-9989
Mailing address:
  • Phone: 812-481-9988
  • Fax: 812-481-9989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20090206
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20090206
License Number StateIN

VIII. Authorized Official

Name: MELISSA M UMALI
Title or Position: OWNER
Credential: PSYD HSPP
Phone: 812-481-9988