Provider Demographics
NPI:1831662345
Name:THOMPSON, NISHELLE
Entity Type:Individual
Prefix:
First Name:NISHELLE
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 1:10417 WILLOWDALE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5619
Mailing Address - Country:US
Mailing Address - Phone:314-422-8716
Mailing Address - Fax:
Practice Address - Street 1:1360 S 5TH ST STE 306
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2447
Practice Address - Country:US
Practice Address - Phone:314-422-8716
Practice Address - Fax:636-493-1884
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MO2018043841101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator