Provider Demographics
NPI:1790968014
Name:THOMAS, CHARLES GERARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GERARD
Last Name:THOMAS
Suffix:
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 1:2417 SHERRY RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1842
Mailing Address - Country:US
Mailing Address - Phone:502-554-6057
Mailing Address - Fax:
Practice Address - Street 1:141 12TH ARMOR DIVISION AVE
Practice Address - Street 2:BLDG 1480
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-6211
Practice Address - Country:US
Practice Address - Phone:502-626-6204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY128135103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical