Healthcare Provider Details

I. General information

NPI: 1700200722
Provider Name (Legal Business Name): THOMAS DE VRIES PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 10/21/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

706 N PENNSYLVANIA AVE
ROSWELL NM
88201
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-0574
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0047C
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number1233
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: