Provider Demographics
NPI:1144719360
Name:COULSON, THOMAS BERNHARD II
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:BERNHARD
Last Name:COULSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RAVENNA DR UNIT 8
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-4033
Mailing Address - Country:US
Mailing Address - Phone:760-368-8048
Mailing Address - Fax:
Practice Address - Street 1:5300 PASEO RANCHO CASTILLA # 2-458
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-4300
Practice Address - Country:US
Practice Address - Phone:760-368-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician