Provider Demographics
NPI:1891435368
Name:EDDY, THOMAS R
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:EDDY
Suffix:
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 1:1625 DEXTER LAKE DR APT 402
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-1327
Mailing Address - Country:US
Mailing Address - Phone:414-915-0511
Mailing Address - Fax:
Practice Address - Street 1:1625 DEXTER LAKE DR APT 402
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-1327
Practice Address - Country:US
Practice Address - Phone:414-915-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0015063101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional