Provider Demographics
NPI:1720116304
Name:MATES, THOMAS ELWIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ELWIN
Last Name:MATES
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 1:7032 WRIGHTSVILLE AVE
Mailing Address - Street 2:SUITE 103B
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3743
Mailing Address - Country:US
Mailing Address - Phone:910-256-6163
Mailing Address - Fax:910-256-6748
Practice Address - Street 1:7032 WRIGHTSVILLE AVE
Practice Address - Street 2:SUITE 103B
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3743
Practice Address - Country:US
Practice Address - Phone:910-256-6163
Practice Address - Fax:910-256-6748
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1092103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000190Medicaid