Provider Demographics
NPI:1508282419
Name:THOMPSON, TERRY (BSW, LAC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:BSW, LAC
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 5453
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-5453
Mailing Address - Country:US
Mailing Address - Phone:406-314-5247
Mailing Address - Fax:406-862-2507
Practice Address - Street 1:840 LUPFER MEADOWS RD
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-8097
Practice Address - Country:US
Practice Address - Phone:406-314-5247
Practice Address - Fax:406-862-2507
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-16
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLAC 1021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT78954OtherCAPS