Provider Demographics
NPI:1760455349
Name:THOMPSON, RON (PHD)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4647 E MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-3167
Mailing Address - Country:US
Mailing Address - Phone:812-333-1160
Mailing Address - Fax:
Practice Address - Street 1:4647 E MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-3167
Practice Address - Country:US
Practice Address - Phone:812-333-1160
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090225103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000235775OtherANTHEM