Provider Demographics
NPI:1669037735
Name:THOMPSON, LORI ELLEN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ELLEN
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 1:3233 ARROYO DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-7207
Mailing Address - Country:US
Mailing Address - Phone:707-816-9359
Mailing Address - Fax:
Practice Address - Street 1:8788 ELK GROVE BLVD STE L
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1768
Practice Address - Country:US
Practice Address - Phone:707-816-9359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-04
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101731106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist