Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 22707 | CA |
N | 103T00000X | Psychologist | 22707 | CA |
Y | 103G00000X | Clinical Psychologist | 22707 | CA |
Y | 103TC0700X | Clinical Psychologist | 22707 | CA |
NPI | 1013142173 |
---|---|
Provider Name | Dr. Thomas Michael Smith |
First Address | Dixon, CA 95620-2172 |
Second Address | Dixon, CA 95620-2172 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2009 |
Last Update Date | 02/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
22707 | BOARD OF PSYCHOLOGY (01) | CA |