Basic Information
| Provider Information | |||||||||
| NPI: | 1225573496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DILLINGHAM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 291943 | ||||||||
| Address2: | 525 ROYAL PARKWAY | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372291943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8339530829 | ||||||||
| FaxNumber: | 8339520829 | ||||||||
| Practice Location | |||||||||
| Address1: | 4421 ROOSEVELT BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450449024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8339520829 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2016 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 161408 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0246686 | 05 | OH | MEDICAID |