Provider Demographics
NPI:1871660217
Name:MERRILL, THOMAS S (PHD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:S
Last Name:MERRILL
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12682 W BAJADA RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2808
Mailing Address - Country:US
Mailing Address - Phone:623-388-4354
Mailing Address - Fax:623-388-4354
Practice Address - Street 1:12682 W BAJADA RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2808
Practice Address - Country:US
Practice Address - Phone:623-388-4354
Practice Address - Fax:623-388-4354
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY243103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIS37782Medicare UPIN
HI000TCBFZMedicare ID - Type Unspecified