Provider Demographics
NPI:1497768089
Name:CAVALLI, THOM FRANK
Entity Type:Individual
Prefix:DR
First Name:THOM
Middle Name:FRANK
Last Name:CAVALLI
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:FRANK
Other - Last Name:CAVALLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1422 CAMEO DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3505
Mailing Address - Country:US
Mailing Address - Phone:714-832-9426
Mailing Address - Fax:
Practice Address - Street 1:540 N GOLDEN CIRCLE DRIVE
Practice Address - Street 2:SUITE 114
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3914
Practice Address - Country:US
Practice Address - Phone:714-731-3238
Practice Address - Fax:714-558-2644
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7180103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist