Healthcare Provider Details

I. General information

NPI: 1811249527
Provider Name (Legal Business Name): BRIAN KEITH THOMSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MADISON ST
SYRACUSE NY
13210-2319
US

IV. Provider business mailing address

620 MADISON ST
SYRACUSE NY
13210-2319
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-7726
  • Fax:
Mailing address:
  • Phone: 315-426-7726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number009939
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: