Provider Demographics
NPI:1437126257
Name:THOMESEN, CHARLENE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:MARIE
Last Name:THOMESEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MIDDLEVILLE RD # 116A
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2200
Mailing Address - Country:US
Mailing Address - Phone:631-754-7963
Mailing Address - Fax:631-754-9350
Practice Address - Street 1:79 MIDDLEVILLE RD # 116A
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2200
Practice Address - Country:US
Practice Address - Phone:631-754-7963
Practice Address - Fax:631-754-9350
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1686532084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry