Healthcare Provider Details

I. General information

NPI: 1316949647
Provider Name (Legal Business Name): THOMAS POLLACK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

170 THOMAS JOHNSON DR STE 200
FREDERICK MD
21702-6200
US

IV. Provider business mailing address

170 THOMAS JOHNSON DR
FREDERICK MD
21702-4354
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-8390
  • Fax: 301-694-7906
Mailing address:
  • Phone: 301-695-8390
  • Fax: 301-694-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2750
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: