Provider Demographics
NPI:1992913370
Name:WILLINGHAM, THOMAS BURTON (MDIV)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BURTON
Last Name:WILLINGHAM
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PASCACK RD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-1124
Mailing Address - Country:US
Mailing Address - Phone:201-391-1935
Mailing Address - Fax:
Practice Address - Street 1:131 PASCACK RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1124
Practice Address - Country:US
Practice Address - Phone:201-391-1935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00193400101YM0800X
NYLMHC002492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health