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General NPI Number Information
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NPI Number | 1750519377
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Entity Type | Individual
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Provider Name | THOMAS PAUL DETTMER PSY.D
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Gender | Male
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Dates
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Enumeration Date | 06/23/2009
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Last Update Date | 08/26/2010
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Provider Practice Location Address
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Address Line | 6223 CONSTITUTION DR
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City | FORT WAYNE
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State | IN
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Zip | 46804-1517
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Country | US
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Telephone | 260-755-5896
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Fax |
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Provider Business Mailing Address
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Address Line | 1614 ALABAMA AVE
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City | FORT WAYNE
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State | IN
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Zip | 46805-5012
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Country | US
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Telephone | 260-609-7007
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 39002939A
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License Number State | IN
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