Provider Demographics
NPI:1104860550
Name:GREGORY A THWAITES PHD PLLC
Entity Type:Organization
Organization Name:GREGORY A THWAITES PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:THWAITES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:970-392-2190
Mailing Address - Street 1:2001 70TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4613
Mailing Address - Country:US
Mailing Address - Phone:970-392-2190
Mailing Address - Fax:970-392-2193
Practice Address - Street 1:2001 70TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4613
Practice Address - Country:US
Practice Address - Phone:970-392-2190
Practice Address - Fax:970-392-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2049103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO803894Medicare ID - Type Unspecified
COCO306749Medicare PIN