Provider Demographics
NPI:1730232513
Name:ATKIN PSY.D.D., THOMAS E (LICENSED CLINICAL PS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:ATKIN PSY.D.D.
Suffix:
Gender:M
Credentials:LICENSED CLINICAL PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO. BOX #6427
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-792-0355
Mailing Address - Fax:435-792-3630
Practice Address - Street 1:545 WEST 465 NORTH
Practice Address - Street 2:STE. #130
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332
Practice Address - Country:US
Practice Address - Phone:435-792-0355
Practice Address - Fax:435-792-3630
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113531-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT660600550029Medicaid
UTCAGH11411306OtherCAQH #
UT660600550029Medicaid