Provider Demographics
NPI:1629639844
Name:THOMPSON, LEGGER THOMAS JR (17131 EXP 1-10-25)
Entity Type:Individual
Prefix:
First Name:LEGGER
Middle Name:THOMAS
Last Name:THOMPSON
Suffix:JR
Gender:M
Credentials:17131 EXP 1-10-25
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2072 N MARKS AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6512
Mailing Address - Country:US
Mailing Address - Phone:559-538-0251
Mailing Address - Fax:
Practice Address - Street 1:2772 S MLK BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:714-366-1457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASUDCR17131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)