Healthcare Provider Details

I. General information

NPI: 1326390279
Provider Name (Legal Business Name): NATHANIEL B THOMAS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 CENTER ST NE
SALEM OR
97301-2669
US

IV. Provider business mailing address

PO BOX 74
DALLAS OR
97338-0074
US

V. Phone/Fax

Practice location:
  • Phone: 503-947-8068
  • Fax:
Mailing address:
  • Phone: 503-947-8068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1018
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number1018
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: