Provider Demographics
NPI:1467678755
Name:AMBERSON, THOMAS GARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GARY
Last Name:AMBERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 YALE AVE
Mailing Address - Street 2:THOMAS G AMBERSON PSYD
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4340
Mailing Address - Country:US
Mailing Address - Phone:909-625-5011
Mailing Address - Fax:909-625-5448
Practice Address - Street 1:419 YALE AVE
Practice Address - Street 2:THOMAS G AMBERSON PSYD
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4340
Practice Address - Country:US
Practice Address - Phone:909-625-5011
Practice Address - Fax:909-625-5448
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9682103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R26495Medicare UPIN
CA00PL96820Medicare ID - Type Unspecified