Provider Demographics
NPI:1518350719
Name:THOMPSON, COREY (LADC)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7975 JUNE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2634
Mailing Address - Country:US
Mailing Address - Phone:320-841-5549
Mailing Address - Fax:
Practice Address - Street 1:7675 MN HWY 13
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378
Practice Address - Country:US
Practice Address - Phone:952-447-4344
Practice Address - Fax:952-447-4346
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303349101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)