Provider Demographics
NPI:1295436202
Name:THOMSEN, MICHAEL JOHN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:THOMSEN
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 1:735 WYMOUNT TER
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2054
Mailing Address - Country:US
Mailing Address - Phone:863-594-7339
Mailing Address - Fax:
Practice Address - Street 1:413 W MONTGOMERY CROSS RD BLDG 600
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3364
Practice Address - Country:US
Practice Address - Phone:615-560-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician