Provider Demographics
NPI:1518335991
Name:THOMPSON, MANDY (MA)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MCBRIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 94TH AVE N STE 250
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2448
Mailing Address - Country:US
Mailing Address - Phone:727-321-3854
Mailing Address - Fax:727-327-7670
Practice Address - Street 1:2116 34TH ST S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-3224
Practice Address - Country:US
Practice Address - Phone:727-321-3854
Practice Address - Fax:727-327-7670
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH17946101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109627000Medicaid