Provider Demographics
NPI:1124372503
Name:THOMPSON, BROOKE R (MS/LPCC)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MS/LPCC
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 24809
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-0809
Mailing Address - Country:US
Mailing Address - Phone:937-309-0906
Mailing Address - Fax:937-365-9010
Practice Address - Street 1:4756 FISHBURG RD STE F
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-5462
Practice Address - Country:US
Practice Address - Phone:937-309-0906
Practice Address - Fax:937-365-9010
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1100092101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0318293Medicaid