MEDICARE: DR. AIRRIELL THOMAS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071011020	IL

General Provider Information

NPI Number	:	1093482184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AIRRIELL THOMAS PSYD

Provider Business Mailing Address
First Line	:	2930 N COMMONWEALTH AVE APT 207
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6285
Country	:	US
Telephone Number	:	773-936-5418
Fax Number	:

Provider Business Practice Location Address
First Line	:	5537 N CLARK ST APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-0751
Country	:	US
Telephone Number	:	773-825-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2021
Last Update Date	:	12/23/2023

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