Provider Demographics
NPI:1790050623
Name:SISTRUNK, THOMAS MATTHEW III
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MATTHEW
Last Name:SISTRUNK
Suffix:III
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 1:2205 S MAIN ST
Mailing Address - Street 2:A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3113
Mailing Address - Country:US
Mailing Address - Phone:915-355-1411
Mailing Address - Fax:
Practice Address - Street 1:2205 S MAIN ST
Practice Address - Street 2:A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3113
Practice Address - Country:US
Practice Address - Phone:915-355-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-10
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1790050623101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor