Provider Demographics
NPI:1508282385
Name:THOMPSON, CLARENCE ALLEY III (MFCC)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:ALLEY
Last Name:THOMPSON
Suffix:III
Gender:M
Credentials:MFCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 4TH AVE
Mailing Address - Street 2:#203
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-8605
Mailing Address - Country:US
Mailing Address - Phone:310-396-1716
Mailing Address - Fax:
Practice Address - Street 1:225 4TH AVE
Practice Address - Street 2:#203
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-8605
Practice Address - Country:US
Practice Address - Phone:310-396-1716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMFC 28772101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 28772OtherCOBRA