Provider Demographics
NPI:1376289827
Name:THOMPSON, DEMITRA GEORGIA
Entity Type:Individual
Prefix:
First Name:DEMITRA
Middle Name:GEORGIA
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 1:412 1ST ST SE REAR LOWER
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-1804
Mailing Address - Country:US
Mailing Address - Phone:240-493-0023
Mailing Address - Fax:
Practice Address - Street 1:20400 OBSERVATION DR STE 104
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4086
Practice Address - Country:US
Practice Address - Phone:240-493-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-21-53740103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst