Provider Demographics
NPI:1508148529
Name:THOMPSON, STACY E (MA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:E
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 FRENCH CREEK RD APT 4
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4374
Mailing Address - Country:US
Mailing Address - Phone:269-873-9344
Mailing Address - Fax:
Practice Address - Street 1:1817 FRENCH CREEK RD APT 4
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4374
Practice Address - Country:US
Practice Address - Phone:269-873-9344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH9312101YM0800X
FLIMT1610106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health