Provider Demographics
NPI:1972822955
Name:THOMPSON, ROSIE LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ROSIE
Middle Name:LEE
Last Name:THOMPSON
Suffix:
Gender:F
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:PO BOX 2831
Mailing Address - Street 2:6425 BIRCH AVENUE
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-0831
Mailing Address - Country:US
Mailing Address - Phone:219-938-7157
Mailing Address - Fax:219-938-7157
Practice Address - Street 1:6425 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-1923
Practice Address - Country:US
Practice Address - Phone:219-938-7157
Practice Address - Fax:219-938-7157
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-29
Last Update Date:2010-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001415A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100071070AMedicaid
IN112430Medicare PIN