Provider Demographics
NPI:1841256716
Name:KNUDSEN, THOMAS EDWARD (PSYD, ABBP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:KNUDSEN
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Gender:M
Credentials:PSYD, ABBP
Other - Prefix:
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Mailing Address - Street 1:22670 SUMMIT DR
Mailing Address - Street 2:STE 2
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-7208
Mailing Address - Country:US
Mailing Address - Phone:315-788-3332
Mailing Address - Fax:315-788-4584
Practice Address - Street 1:531 WASHINGTON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-788-3332
Practice Address - Fax:315-788-4584
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY014488103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical