Provider Demographics
NPI:1952363426
Name:THOMAS, KATHY LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:LEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 NE HOLLADAY ST STE 1600
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2035
Mailing Address - Country:US
Mailing Address - Phone:503-860-0042
Mailing Address - Fax:
Practice Address - Street 1:650 NE HOLLADAY ST STE 1600
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2035
Practice Address - Country:US
Practice Address - Phone:503-860-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3634103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ855306Medicaid
AZ79435Medicare ID - Type Unspecified
AZZ147523Medicare PIN