Provider Demographics
NPI:1326145806
Name:PEDERSEN, THOMAS WILLIAM (PSYD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILLIAM
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 KAILORS COVE CIR
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-3372
Mailing Address - Country:US
Mailing Address - Phone:423-580-8896
Mailing Address - Fax:
Practice Address - Street 1:561 KAILORS COVE CIR
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-3372
Practice Address - Country:US
Practice Address - Phone:423-580-8896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001751103TC0700X
GAPSY002564103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN680011023OtherRR MEDICARE W PARADIGM
TN3584286Medicaid
TN3138951OtherBCBS W PARADIGM
GA235954957BMedicaid
TN3584286Medicaid
TN3980240Medicare PIN
TN680011023OtherRR MEDICARE W PARADIGM