Provider Demographics
NPI:1265651046
Name:HIGGINS, THOMAS MICHAEL (MA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:HIGGINS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 N CENTRAL AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1809
Mailing Address - Country:US
Mailing Address - Phone:818-247-1234
Mailing Address - Fax:818-247-4203
Practice Address - Street 1:633 N CENTRAL AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1809
Practice Address - Country:US
Practice Address - Phone:818-247-1234
Practice Address - Fax:818-247-4203
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2712231H00000X
CAAU312231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ958492Medicaid
CAZZZ958492Medicaid