Healthcare Provider Details

I. General information

NPI: 1720116304
Provider Name (Legal Business Name): THOMAS ELWIN MATES PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7032 WRIGHTSVILLE AVE SUITE 103B
WILMINGTON NC
28403-3743
US

IV. Provider business mailing address

7032 WRIGHTSVILLE AVE SUITE 103B
WILMINGTON NC
28403-3743
US

V. Phone/Fax

Practice location:
  • Phone: 910-256-6163
  • Fax: 910-256-6748
Mailing address:
  • Phone: 910-256-6163
  • Fax: 910-256-6748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1092
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1092
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: