Provider Demographics
NPI:1477642635
Name:BILLOTTI, THOMAS J (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:BILLOTTI
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 1:225 H SPRINGMEDOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741
Mailing Address - Country:US
Mailing Address - Phone:631-360-3616
Mailing Address - Fax:631-360-3616
Practice Address - Street 1:20 GILBERT AVE
Practice Address - Street 2:SUITE 102B
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-360-3616
Practice Address - Fax:631-360-3616
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0081251103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0059283OtherGHI
AH00118OtherMDNY
0059283OtherGHI