Provider Demographics
NPI:1396526307
Name:ETTINGER, THOMAS EGLESTON (DR/PHD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EGLESTON
Last Name:ETTINGER
Suffix:
Gender:M
Credentials:DR/PHD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:ETTINGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:623 WEST 145 ST
Mailing Address - Street 2:FL 2
Mailing Address - City:NYC
Mailing Address - State:NY
Mailing Address - Zip Code:10031-5000
Mailing Address - Country:US
Mailing Address - Phone:917-553-4320
Mailing Address - Fax:
Practice Address - Street 1:623 WEST 145 ST
Practice Address - Street 2:FL 2
Practice Address - City:NYC
Practice Address - State:NY
Practice Address - Zip Code:10031-5000
Practice Address - Country:US
Practice Address - Phone:917-553-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0200X
NY014375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic