Provider Demographics
NPI:1407060833
Name:DIMITRY, THOMAS LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEE
Last Name:DIMITRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 N MAPLE AVE
Mailing Address - Street 2:SUITE 204E
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3255
Mailing Address - Country:US
Mailing Address - Phone:201-445-6677
Mailing Address - Fax:
Practice Address - Street 1:61 N MAPLE AVE
Practice Address - Street 2:SUITE 204E
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3255
Practice Address - Country:US
Practice Address - Phone:201-445-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3800103TB0200X, 103TC0700X, 103TC2200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool