Provider Demographics
NPI:1740229483
Name:WILLETT, THOMAS G
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:WILLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 LOMITA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5041
Mailing Address - Country:US
Mailing Address - Phone:310-534-9131
Mailing Address - Fax:310-534-9132
Practice Address - Street 1:4477 W 118TH ST
Practice Address - Street 2:400
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2255
Practice Address - Country:US
Practice Address - Phone:310-978-1214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA228262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A228260Medicaid
CAA22826OtherMEDICAL BOARD OF CA
CA00A228260Medicaid