Provider Demographics
NPI:1194973131
Name:TOM NEGRON, PH.D, PA
Entity type:Organization
Organization Name:TOM NEGRON, PH.D, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:NEGRON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-772-1164
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-0788
Mailing Address - Country:US
Mailing Address - Phone:207-772-1164
Mailing Address - Fax:
Practice Address - Street 1:4 CUMMINGS DR
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-2452
Practice Address - Country:US
Practice Address - Phone:207-772-1164
Practice Address - Fax:207-772-2670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPSY712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010823 N0705OtherANTHEM BLUE CROSS
ME126410000Medicaid
ME010823 N0705OtherANTHEM BLUE CROSS