Provider Demographics
NPI:1639127558
Name:THORNBERRY, THOMAS W (MA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:W
Last Name:THORNBERRY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLUEGRASS HEALTH PSYCHOLOGY, INC.
Mailing Address - Street 2:4101 TATES CREEK CTR DR, STE 150 PMB 123
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3066
Mailing Address - Country:US
Mailing Address - Phone:859-277-1008
Mailing Address - Fax:859-277-1083
Practice Address - Street 1:BLUEGRASS HEALTH PSYCHOLOGY, INC.
Practice Address - Street 2:2220 YOUNG DRIVE
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-4219
Practice Address - Country:US
Practice Address - Phone:859-277-1008
Practice Address - Fax:859-277-1083
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0043103TB0200X
KY114440103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
1228477OtherCHA
KY7100417130Medicaid
000000478236OtherANTHEM
KYP32056Medicare UPIN
KY0366218Medicare PIN