Provider Demographics
NPI:1609587617
Name:THOMPSON, DERRIC
Entity Type:Individual
Prefix:
First Name:DERRIC
Middle Name:
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 1:2301 W DUNLAP AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2846
Mailing Address - Country:US
Mailing Address - Phone:480-909-6847
Mailing Address - Fax:
Practice Address - Street 1:2301 W DUNLAP AVE STE 206
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2846
Practice Address - Country:US
Practice Address - Phone:480-909-6847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst