Provider Demographics
NPI:1376956490
Name:THOMPSON, ANGEL LATRECE
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:LATRECE
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 1:2113 N MAIN ST
Mailing Address - Street 2:APT # 204
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4039
Mailing Address - Country:US
Mailing Address - Phone:918-693-3806
Mailing Address - Fax:
Practice Address - Street 1:1217 E 33RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-2017
Practice Address - Country:US
Practice Address - Phone:918-779-4556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health