Provider Demographics
NPI:1821019357
Name:MRAZ, THOMAS J (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:MRAZ
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:PO BOX 45075
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-0075
Mailing Address - Country:US
Mailing Address - Phone:831-917-7900
Mailing Address - Fax:
Practice Address - Street 1:20800 WESTGATE MALL
Practice Address - Street 2:SUITE 103
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-1323
Practice Address - Country:US
Practice Address - Phone:831-901-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7441103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC 70044FOtherMEDI-CAL GROUP PROVIDER#
CAZZZ91891ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAPSY 20869OtherPSYCHOLOGIST LICENSE
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAFHC 70042FOtherMEDI-CAL GROUP PROVIDER#