Basic Information
| Provider Information | |||||||||
| NPI: | 1982184792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMSON | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | JAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4913 W RENO AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731276339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059484900 | ||||||||
| FaxNumber: | 4059484933 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 S ANN ARBOR AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731281112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059484900 | ||||||||
| FaxNumber: | 4059484933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.