Provider Demographics
NPI:1629280136
Name:THOMPSON, VIVIAN STANFORD (LCSWR)
Entity Type:Individual
Prefix:MR
First Name:VIVIAN
Middle Name:STANFORD
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 COURT ST STE 1502
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11242-1115
Mailing Address - Country:US
Mailing Address - Phone:917-204-7852
Mailing Address - Fax:631-648-8915
Practice Address - Street 1:26 COURT STREET
Practice Address - Street 2:SUITE 410 D
Practice Address - City:BROOKLYN, NY
Practice Address - State:NY
Practice Address - Zip Code:11242
Practice Address - Country:US
Practice Address - Phone:646-263-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0596101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1111003OtherAETNA
NY02644324Medicaid
NYMH00179OtherNYHTC HEALTH BENEFIT FUND
NY000370015569OtherHEALTH PLUS, INC.
NYN09A41Medicare ID - Type UnspecifiedLCSWR