Provider Demographics
NPI:1669005377
Name:THOMPSON, SHELLY M
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:M
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 1:4640 VEGAS VALLEY DR APT 2093
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7915
Mailing Address - Country:US
Mailing Address - Phone:702-600-6791
Mailing Address - Fax:
Practice Address - Street 1:601 S RANCHO DR STE A10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4898
Practice Address - Country:US
Practice Address - Phone:702-437-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health