Provider Demographics
NPI:1730319617
Name:THOMPSON, MICAH J
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1423
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:
Practice Address - Street 1:4710 CHAMPIONS TRACE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3495
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-25
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106367106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist