Basic Information
| Provider Information | |||||||||
| NPI: | 1316949647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLLACK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 THOMAS JOHNSON DR | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016958390 | ||||||||
| FaxNumber: | 3016947906 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 THOMAS JOHNSON DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217026200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016958390 | ||||||||
| FaxNumber: | 3016947906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/20/2006 | ||||||||
| NPIReactivationDate: | 03/27/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2750 | MD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 339104 | 01 | MD | MAMSI | OTHER |