Provider Demographics
NPI:1528557790
Name:THOMPSON, CHARLENE (SAC-IT)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 W NORTH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1333
Mailing Address - Country:US
Mailing Address - Phone:414-467-8884
Mailing Address - Fax:
Practice Address - Street 1:1134 W. NORTH AVE, SECOND FLOOR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205
Practice Address - Country:US
Practice Address - Phone:414-467-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)