Provider Demographics
NPI:1356849996
Name:THOM, LILY ANNA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LILY
Middle Name:ANNA
Last Name:THOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 DOUGLASS ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-4774
Mailing Address - Country:US
Mailing Address - Phone:347-834-3771
Mailing Address - Fax:
Practice Address - Street 1:175 W 13TH ST APT 1B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7803
Practice Address - Country:US
Practice Address - Phone:347-834-3771
Practice Address - Fax:347-834-3771
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022548103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist