MEDICARE: DR. THOMAS PAUL DETTMER PSY.D

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	39002939A	IN

General Provider Information

NPI Number	:	1750519377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS PAUL DETTMER PSY.D

Provider Business Mailing Address
First Line	:	1614 ALABAMA AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5012
Country	:	US
Telephone Number	:	260-609-7007
Fax Number	:

Provider Business Practice Location Address
First Line	:	6223 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1517
Country	:	US
Telephone Number	:	260-755-5896
Fax Number	:

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

Provider Enumeration Date	:	06/23/2009
Last Update Date	:	08/26/2010

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