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General NPI Number Information
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NPI Number | 1215056809
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Entity Type | Individual
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Provider Name | EVAN MILLER THOMAS PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 108 E PONCE DE LEON AVE STE 204
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City | DECATUR
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State | GA
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Zip | 30030-2512
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Country | US
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Telephone | 510-566-2367
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Fax |
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Provider Business Mailing Address
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Address Line | 25857 FOOTHILLS DR N
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City | GOLDEN
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State | CO
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Zip | 80401-8556
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Country | US
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Telephone | 510-566-2367
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | D6540235
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY003899
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License Number State | GA
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