Provider Demographics
NPI:1568826998
Name:THOMAS, MICHAEL ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2184 CHANNING WAY # 119
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8034
Mailing Address - Country:US
Mailing Address - Phone:208-728-7750
Mailing Address - Fax:
Practice Address - Street 1:2184 CHANNING WAY # 119
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8034
Practice Address - Country:US
Practice Address - Phone:208-728-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2401103TC0700X
ID7471153103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical