Provider Demographics
NPI:1578754933
Name:MCCANN, THOMAS MATTHEW (PSYD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MATTHEW
Last Name:MCCANN
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 1:3333 BURNET AVE
Mailing Address - Street 2:MLC 3015
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4336
Mailing Address - Fax:513-636-3497
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:MLC 3015
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4336
Practice Address - Fax:513-636-3497
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
OH7335103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30607030Medicaid
KY611041631OtherTAX ID GROUP FOR COUNSELING AND DIAGNOSTIC CENTER
KY611041631OtherTAX ID GROUP FOR COUNSELING AND DIAGNOSTIC CENTER