Provider Demographics
NPI:1386867729
Name:THOMPSON, KELLY RICHARD (CAARR)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:RICHARD
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CAARR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2169 ALLUVIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6633
Mailing Address - Country:US
Mailing Address - Phone:559-297-1733
Mailing Address - Fax:
Practice Address - Street 1:2169 ALLUVIAL AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6633
Practice Address - Country:US
Practice Address - Phone:559-297-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02-054242101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)