Provider Demographics
NPI:1326718511
Name:THOMPSON, ANTHONY MARCILOUS
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MARCILOUS
Last Name:THOMPSON
Suffix:
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 1:29473 N CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-3801
Mailing Address - Country:US
Mailing Address - Phone:623-455-2280
Mailing Address - Fax:
Practice Address - Street 1:29473 N CANDLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-3801
Practice Address - Country:US
Practice Address - Phone:623-455-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20147101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor