Provider Demographics
NPI:1013201698
Name:THOMPSON, MITCHELL
Entity Type:Individual
Prefix:MS
First Name:MITCHELL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 RAMSEY STREET
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301
Mailing Address - Country:US
Mailing Address - Phone:910-000-0000
Mailing Address - Fax:
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0105991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical