Provider Demographics
NPI:1790887669
Name:THOMALLA, ANTHONY ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:ALAN
Last Name:THOMALLA
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 1:1915 S G ST
Mailing Address - Street 2:STE 2
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-6511
Mailing Address - Country:US
Mailing Address - Phone:765-960-0942
Mailing Address - Fax:
Practice Address - Street 1:1915 S G ST
Practice Address - Street 2:STE 2
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-6511
Practice Address - Country:US
Practice Address - Phone:307-349-6080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040651A103TA0400X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0200X, 103TH0100X, 103TM1800X, 103TP2701X, 103TR0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00396776OtherRAILROAD
IN100092720BMedicaid
IN100092720BMedicaid