Provider Demographics
NPI:1669015590
Name:THOMPSON, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
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 1:6009 ED COADY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-2502
Mailing Address - Country:US
Mailing Address - Phone:817-228-0399
Mailing Address - Fax:
Practice Address - Street 1:6733 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7112
Practice Address - Country:US
Practice Address - Phone:817-386-9180
Practice Address - Fax:817-386-9138
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)