Provider Demographics
NPI:1578212577
Name:THOMPSON, CHANDLER JAMES
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:JAMES
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 E LADY BUG LN
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8338
Mailing Address - Country:US
Mailing Address - Phone:208-518-7434
Mailing Address - Fax:
Practice Address - Street 1:7905 N MEADOWLARK WAY STE D
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5041
Practice Address - Country:US
Practice Address - Phone:208-417-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNIS971500383OtherBLUE CROSS OF IDAHO