Provider Demographics
NPI:1467590802
Name:THOMAS, RANDALL STEPHEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:STEPHEN
Last Name:THOMAS
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 1:3 LOOCKERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-4905
Mailing Address - Country:US
Mailing Address - Phone:845-471-2267
Mailing Address - Fax:860-868-1288
Practice Address - Street 1:3 LOOCKERMAN AVE
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4905
Practice Address - Country:US
Practice Address - Phone:845-471-2267
Practice Address - Fax:860-868-1288
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8681-1103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01272-13Medicaid
NY01272-13Medicaid
NYV65311Medicare ID - Type UnspecifiedMEDICARE