Provider Demographics
NPI:1952325169
Name:THOMAS, TERESA ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:ELLEN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1516 OAK ST
Mailing Address - Street 2:STE. 313
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2947
Mailing Address - Country:US
Mailing Address - Phone:510-340-9196
Mailing Address - Fax:510-340-9197
Practice Address - Street 1:1516 OAK ST
Practice Address - Street 2:STE. 313
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2947
Practice Address - Country:US
Practice Address - Phone:510-340-9196
Practice Address - Fax:510-340-9197
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16869103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL168690Medicare ID - Type Unspecified
CAP23302Medicare UPIN