Provider Demographics
NPI:1386223212
Name:THOMPSON, BRIAN KELSEY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KELSEY
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 NE SKIDMORE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3475
Mailing Address - Country:US
Mailing Address - Phone:503-280-3624
Mailing Address - Fax:
Practice Address - Street 1:1017 NE SKIDMORE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3475
Practice Address - Country:US
Practice Address - Phone:503-280-3624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL43441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical