Provider Demographics
NPI:1215056809
Name:THOMAS, EVAN MILLER (PSYD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:MILLER
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25857 FOOTHILLS DR N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-8556
Mailing Address - Country:US
Mailing Address - Phone:510-566-2367
Mailing Address - Fax:
Practice Address - Street 1:108 E PONCE DE LEON AVE STE 204
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2512
Practice Address - Country:US
Practice Address - Phone:510-566-2367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6540235101Y00000X
GAPSY003899103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
11415OtherSFGH INTERNAL USE ONLY
11415OtherCBHS INTERNAL USE ONLY-COMMERCIAL NUMBER