Provider Demographics
NPI:1861004806
Name:THOMPSON, MATTHEW (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3267
Mailing Address - Country:US
Mailing Address - Phone:575-489-4750
Mailing Address - Fax:
Practice Address - Street 1:1700 N UNION AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3267
Practice Address - Country:US
Practice Address - Phone:575-489-4750
Practice Address - Fax:575-586-4414
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-33471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical