Provider Demographics
NPI:1013142173
Name:SMITH, THOMAS MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N LINCOLN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-2172
Mailing Address - Country:US
Mailing Address - Phone:707-235-8600
Mailing Address - Fax:707-678-0666
Practice Address - Street 1:805 N LINCOLN ST
Practice Address - Street 2:SUITE B
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-2172
Practice Address - Country:US
Practice Address - Phone:707-235-8600
Practice Address - Fax:707-678-0666
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22707103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22707OtherBOARD OF PSYCHOLOGY
EE765AMedicare PIN