Provider Demographics
NPI:1659389617
Name:RENFROE, THOMAS WILSON JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILSON
Last Name:RENFROE
Suffix:JR
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 1:2010 SYBIL LN
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1818
Mailing Address - Country:US
Mailing Address - Phone:903-596-8118
Mailing Address - Fax:903-596-8125
Practice Address - Street 1:2010 SYBIL LN
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1818
Practice Address - Country:US
Practice Address - Phone:903-596-8118
Practice Address - Fax:903-596-8125
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24047103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86292AOtherBCBS
TX033724801Medicaid
TX00131RMedicare ID - Type Unspecified