Healthcare Provider Details

I. General information

NPI: 1790887669
Provider Name (Legal Business Name): ANTHONY ALAN THOMALLA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 S G ST STE 2
RICHMOND IN
47374-6511
US

IV. Provider business mailing address

1915 S G ST STE 2
RICHMOND IN
47374-6511
US

V. Phone/Fax

Practice location:
  • Phone: 307-349-6080
  • Fax:
Mailing address:
  • Phone: 765-960-0942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP5573
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number20040651A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040651A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20040651A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number20040651A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number20040651A
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20040651A
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number20040651A
License Number StateIN
# 9
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number20040651A
License Number StateIN
# 10
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number20040651A
License Number StateIN
# 11
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20040651A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: