Provider Demographics
NPI:1639347701
Name:TOM, TANYA L (PHD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:TOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 THOMES AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2734
Mailing Address - Country:US
Mailing Address - Phone:307-638-2164
Mailing Address - Fax:
Practice Address - Street 1:507 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4617
Practice Address - Country:US
Practice Address - Phone:307-637-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical