Provider Demographics
NPI:1770773319
Name:THOMAS III, FRED S III (CERTIFIED HYPNOSIS)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:S
Last Name:THOMAS III
Suffix:III
Gender:M
Credentials:CERTIFIED HYPNOSIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740096
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92174-0096
Mailing Address - Country:US
Mailing Address - Phone:619-262-3159
Mailing Address - Fax:
Practice Address - Street 1:2423 CAMION DEL RIO
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:619-683-2104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional