Provider Demographics
NPI:1578591806
Name:THOMPSON, GARY L (MA, MSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7734 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9796
Mailing Address - Country:US
Mailing Address - Phone:269-372-9658
Mailing Address - Fax:269-743-1000
Practice Address - Street 1:7734 S 8TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-9796
Practice Address - Country:US
Practice Address - Phone:269-372-9658
Practice Address - Fax:269-743-1000
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI047372OtherVALUEOPTIONS PROVIDER NUM
MI71020000893826OtherBCBS PROVIDER NUMBER