Provider Demographics
NPI:1467623793
Name:THOMPSON, MUSTAFA LATIF
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:LATIF
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 1:350 MEADOW STREET
Mailing Address - Street 2:APT 43
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001
Mailing Address - Country:US
Mailing Address - Phone:413-219-6622
Mailing Address - Fax:
Practice Address - Street 1:2112 RIVERDALE STREET
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-827-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health