Provider Demographics
NPI:1689109910
Name:THOMPSON, KOI
Entity Type:Individual
Prefix:
First Name:KOI
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 1:374 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RESERVE
Mailing Address - State:LA
Mailing Address - Zip Code:70084-6504
Mailing Address - Country:US
Mailing Address - Phone:985-703-1083
Mailing Address - Fax:
Practice Address - Street 1:374 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:LA
Practice Address - Zip Code:70084-6504
Practice Address - Country:US
Practice Address - Phone:985-703-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health