Provider Demographics
NPI:1417015413
Name:THOMPSON, KEVIN LEE
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
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:PO BOX 3371
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-3371
Mailing Address - Country:US
Mailing Address - Phone:707-350-5536
Mailing Address - Fax:
Practice Address - Street 1:6302 13TH STREET
Practice Address - Street 2:
Practice Address - City:LUCERNE
Practice Address - State:CA
Practice Address - Zip Code:95458-8106
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:707-994-7096
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health