Basic Information
| Provider Information | |||||||||
| NPI: | 1457766156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THAYER | ||||||||
| FirstName: | DESMOND | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PRISON RD | ||||||||
| Address2: | |||||||||
| City: | REPRESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956713000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169858610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 PRISON RD | ||||||||
| Address2: | |||||||||
| City: | REPRESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956712501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169858610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2014 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY29042 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.