Provider Demographics
NPI:1396856753
Name:TYRRELL, THOMAS J (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:TYRRELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1533 S SAINT FRANCIS DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4032
Mailing Address - Country:US
Mailing Address - Phone:505-988-4131
Mailing Address - Fax:505-982-6145
Practice Address - Street 1:1533 S SAINT FRANCIS DR
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4032
Practice Address - Country:US
Practice Address - Phone:505-988-4131
Practice Address - Fax:505-982-6145
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0928103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA 1096Medicaid
NMA 1096Medicaid