Healthcare Provider Details

I. General information

NPI: 1407362874
Provider Name (Legal Business Name): THOMAS WYKES JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 REGENCY DR
LARAMIE WY
82070-5106
US

IV. Provider business mailing address

2015 CENTRAL AVE STE F
CHEYENNE WY
82001-3754
US

V. Phone/Fax

Practice location:
  • Phone: 307-222-4376
  • Fax:
Mailing address:
  • Phone: 480-332-7146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number643
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: