Provider Demographics
NPI:1700200722
Name:DE VRIES, THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:DE VRIES
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 1:706 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 W COUTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:505-273-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0047C103TP0016X
NM1233103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1233OtherNM STATE BOARD OF PSYCHOLOGIST EXAMINERS LICENSE