Provider Demographics
NPI:1902362346
Name:THOMPSON, KIMBERLY RAYE (TLLP, BCABA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAYE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:TLLP, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W WASHINGTON ST STE 106
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4350
Mailing Address - Country:US
Mailing Address - Phone:906-228-8881
Mailing Address - Fax:906-228-4549
Practice Address - Street 1:102 W WASHINGTON ST STE 106
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4350
Practice Address - Country:US
Practice Address - Phone:906-228-8881
Practice Address - Fax:906-228-4549
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-18-66046106S00000X
MI6362008876103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician