Provider Demographics
NPI:1508871344
Name:THAYER, DAVID L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:THAYER
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 1:821 W SOUTH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-4684
Mailing Address - Country:US
Mailing Address - Phone:269-501-3493
Mailing Address - Fax:
Practice Address - Street 1:821 W SOUTH ST
Practice Address - Street 2:SUITE D
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4684
Practice Address - Country:US
Practice Address - Phone:269-501-3493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008205103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680D16189OtherBC/BS
MI680D16189OtherBC/BS