Provider Demographics
NPI:1225573496
Name:DILLINGHAM, THOMAS JR (LICDC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DILLINGHAM
Suffix:JR
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 291943
Mailing Address - Street 2:525 ROYAL PARKWAY
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37229-1943
Mailing Address - Country:US
Mailing Address - Phone:833-953-0829
Mailing Address - Fax:833-952-0829
Practice Address - Street 1:4421 ROOSEVELT BLVD STE A
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-9024
Practice Address - Country:US
Practice Address - Phone:833-952-0829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161408101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0246686Medicaid