Provider Demographics
NPI:1639768823
Name:THOMPSON, EBONI NICOLE
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:NICOLE
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 1:320 W PIKE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4866
Mailing Address - Country:US
Mailing Address - Phone:678-278-9244
Mailing Address - Fax:678-412-1679
Practice Address - Street 1:320 W PIKE ST STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4866
Practice Address - Country:US
Practice Address - Phone:678-278-9244
Practice Address - Fax:678-412-1679
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist