Provider Demographics
NPI:1427128859
Name:THOMAS, BORIS (PHD, LCSW)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 W 115TH ST # 253
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7722
Mailing Address - Country:US
Mailing Address - Phone:312-279-7575
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE STE 602
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6601
Practice Address - Country:US
Practice Address - Phone:917-224-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2015-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0102191041C0700X
NY081412-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-01029OtherIL LCSW LIC NO.
IL01632700OtherBLUECROSSBLUESHIELD NO.
IL480484OtherVALUE OPTIONS PROVIDER NO
NYR-081412-1OtherNY LCSW
IL149-01029OtherIL LCSW LIC NO.
NYR-081412-1OtherNY LCSW