Provider Demographics
NPI:1558829432
Name:THOMPSON, TYESHA
Entity Type:Individual
Prefix:
First Name:TYESHA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2749
Mailing Address - Country:US
Mailing Address - Phone:508-405-5696
Mailing Address - Fax:
Practice Address - Street 1:39 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2749
Practice Address - Country:US
Practice Address - Phone:508-405-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-09
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty