Basic Information
| Provider Information | |||||||||
| NPI: | 1275817322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13193 CENTRAL AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917104179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099029111 | ||||||||
| FaxNumber: | 9099029199 | ||||||||
| Practice Location | |||||||||
| Address1: | 13193 CENTRAL AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917104179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099029111 | ||||||||
| FaxNumber: | 9099029199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2011 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY22044 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | CA | CAQH PENDING | OTHER |