Provider Demographics
NPI:1922878727
Name:THOMPSON, MISTY J
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:J
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3208 HERSHBERGER RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-1842
Mailing Address - Country:US
Mailing Address - Phone:540-912-4211
Mailing Address - Fax:
Practice Address - Street 1:3208 HERSHBERGER RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-1842
Practice Address - Country:US
Practice Address - Phone:540-912-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)