Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 5238 | OH |
NPI | 1053445825 |
---|---|
Provider Name | Glenn V Thomas |
First Address | Detroit, MI 48278-1625 |
Second Address | Columbus, OH 43215-5384 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2007 |
Last Update Date | 23/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1473276 | (05) | OH |