Provider Demographics
NPI:1932667292
Name:THOMPSON, TRACI (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14949 62ND ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6102
Mailing Address - Country:US
Mailing Address - Phone:651-430-6620
Mailing Address - Fax:651-430-6527
Practice Address - Street 1:14949 62ND ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6102
Practice Address - Country:US
Practice Address - Phone:651-430-6620
Practice Address - Fax:651-430-6527
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN173941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical