Provider Demographics
NPI:1639675036
Name:THOMPSON, TERESA DAWN
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:DAWN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7229 BLUEBIRD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2803
Mailing Address - Country:US
Mailing Address - Phone:248-935-3803
Mailing Address - Fax:
Practice Address - Street 1:7229 BLUEBIRD
Practice Address - Street 2:
Practice Address - City:WATERFORD TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48329-2803
Practice Address - Country:US
Practice Address - Phone:248-935-3803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator