Provider Demographics
NPI:1720450836
Name:MOMOH, THOMAS (RADT-I)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MOMOH
Suffix:
Gender:M
Credentials:RADT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 N B ST STE E
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-0326
Mailing Address - Country:US
Mailing Address - Phone:916-378-8266
Mailing Address - Fax:
Practice Address - Street 1:1103 N B ST STE E
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0326
Practice Address - Country:US
Practice Address - Phone:916-378-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
CAR1219871215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)