Provider Demographics
NPI:1104394725
Name:THOMPSON, ALICE CHINN
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:CHINN
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 1:47 SYMPHONY RD APT 103
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-4012
Mailing Address - Country:US
Mailing Address - Phone:978-618-3134
Mailing Address - Fax:
Practice Address - Street 1:75 FENWOOD RD FL 5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6103
Practice Address - Country:US
Practice Address - Phone:617-754-1239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHPP54540802OtherHARVARD PILGRIM