Provider Demographics
NPI:1760914311
Name:THOMPSON, ANGELA (LCDCIII161378)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LCDCIII161378
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:440-989-4987
Mailing Address - Fax:440-246-0189
Practice Address - Street 1:2115 W PARK DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053
Practice Address - Country:US
Practice Address - Phone:440-989-4987
Practice Address - Fax:440-246-0189
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161378101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLCDCIII.161378OtherLICENSE