Provider Demographics
NPI:1609933126
Name:BALMER, THOM DANIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOM
Middle Name:DANIEL
Last Name:BALMER
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 1:901 EAST 16TH STREET
Mailing Address - Street 2:ARBUCKLE LIFE SOLUTIONS
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-559-5839
Mailing Address - Fax:
Practice Address - Street 1:901 EAST 16TH STREET
Practice Address - Street 2:ARBUCKLE LIFE SOLUTIONS
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-226-1656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1028101YP2500X, 101YM0800X
OK699106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health