Provider Demographics
NPI:1922865450
Name:WHITESIDE, THOMAS (BT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:M
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10809 NATCHES TRCE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-5374
Mailing Address - Country:US
Mailing Address - Phone:757-510-5899
Mailing Address - Fax:
Practice Address - Street 1:1510 GREENLAWN BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7072
Practice Address - Country:US
Practice Address - Phone:757-510-5899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician