Provider Demographics
NPI:1043440704
Name:HOLLEY, THOMAS ROUSE (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ROUSE
Last Name:HOLLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:MSC06 3870
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-277-3136
Mailing Address - Fax:505-277-2020
Practice Address - Street 1:5801 EUBANK BLVD NE
Practice Address - Street 2:APT. # 69
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6123
Practice Address - Country:US
Practice Address - Phone:510-459-0180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77-452084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25478Medicaid
NM25478Medicaid