Provider Demographics
NPI:1932186889
Name:HOLSWORTH, THOMAS E (PHD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:HOLSWORTH
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 MANNHEIM RD SIDE G
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9617
Mailing Address - Country:US
Mailing Address - Phone:812-481-9988
Mailing Address - Fax:812-481-9989
Practice Address - Street 1:4201 MANNHEIM RD SIDE G
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-9617
Practice Address - Country:US
Practice Address - Phone:812-481-9988
Practice Address - Fax:812-481-9989
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090206A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100109690AMedicaid
281910AMedicare ID - Type Unspecified
R33452Medicare UPIN