Provider Demographics
NPI:1912959602
Name:TASHJIAN, THOMAS A (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:TASHJIAN
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 1:1148 OLD TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:OAKHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01068-9824
Mailing Address - Country:US
Mailing Address - Phone:508-860-1049
Mailing Address - Fax:
Practice Address - Street 1:246 WALNUT ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02460-1689
Practice Address - Country:US
Practice Address - Phone:617-244-3322
Practice Address - Fax:617-244-1827
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3022103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03456OtherBLUE CROSS BLUE SHIELD OF
MA0525154Medicaid
MAW03456OtherBLUE CROSS BLUE SHIELD OF