Provider Demographics
NPI:1003929274
Name:MILLARD, THOMAS LEE (PHD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LEE
Last Name:MILLARD
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 1:1523 S BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-6549
Mailing Address - Country:US
Mailing Address - Phone:563-243-6054
Mailing Address - Fax:
Practice Address - Street 1:1523 S BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-6549
Practice Address - Country:US
Practice Address - Phone:563-243-6054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA23379OtherBLUE CROSS BLUE SHIELD
IA23379OtherBLUE CROSS BLUE SHIELD