Provider Demographics
NPI:1598342891
Name:MOREIRA, THIAGO BOMFIM (MS, SPECIALIST, BA)
Entity Type:Individual
Prefix:MR
First Name:THIAGO
Middle Name:BOMFIM
Last Name:MOREIRA
Suffix:
Gender:M
Credentials:MS, SPECIALIST, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RUA FRANCISCO PESSOA 491/102
Mailing Address - Street 2:
Mailing Address - City:SAO PAULO
Mailing Address - State:BRAZIL
Mailing Address - Zip Code:05727230
Mailing Address - Country:BR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RUA GOMES DE CARVALHO 1356, 5TH FLOOR
Practice Address - Street 2:
Practice Address - City:SAO PAULO
Practice Address - State:SAO PAULO
Practice Address - Zip Code:05727230
Practice Address - Country:BR
Practice Address - Phone:540-209-7443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ZZ154587103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
06154587OtherFEDERAL PSYCHOLOGY BOARD