Provider Demographics
NPI:1588824478
Name:THOMPSON, NICOLE JANE (PMHNP-BC,LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JANE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PMHNP-BC,LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8430 MEDICAL PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9758
Practice Address - Country:US
Practice Address - Phone:704-910-6142
Practice Address - Fax:980-422-0106
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076873104100000X
FLSW119081041C0700X
MA1149121041C0700X
TX539481041C0700X
NC5018004363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01506383Medicare PIN
FLHZ220ZMedicare PIN
MA213382OtherSTATE OF MASSACHUSETTS LCSW
FLP01506383Medicare PIN
FLHZ220ZMedicare PIN