Provider Demographics
NPI:1417173105
Name:DAVIS, THOMSON F (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMSON
Middle Name:F
Last Name:DAVIS
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 1:3537 LAKE ELMO AVE N
Mailing Address - Street 2:P.O. BOX 277
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-7405
Mailing Address - Country:US
Mailing Address - Phone:651-773-2010
Mailing Address - Fax:
Practice Address - Street 1:3537 LAKE ELMO AVE N
Practice Address - Street 2:SUITE 190
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-7405
Practice Address - Country:US
Practice Address - Phone:651-773-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1034103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent