Provider Demographics
NPI:1235738105
Name:THOMPSON, DEMETRIUS II
Entity Type:Individual
Prefix:MR
First Name:DEMETRIUS
Middle Name:
Last Name:THOMPSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1974 WALTON NICHOLSON PIKE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-7906
Mailing Address - Country:US
Mailing Address - Phone:859-359-5404
Mailing Address - Fax:859-359-0739
Practice Address - Street 1:1974 WALTON NICHOLSON PIKE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051-7906
Practice Address - Country:US
Practice Address - Phone:859-359-5404
Practice Address - Fax:859-359-0739
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)