Provider Demographics
NPI:1851023147
Name:THOMPSON, MATTHEW PRESCOTT (LLMSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PRESCOTT
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 E SOUTHERN AVE STE 100
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5041
Practice Address - Country:US
Practice Address - Phone:231-672-3582
Practice Address - Fax:231-722-6933
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851114625104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker