Provider Demographics
NPI:1184063448
Name:THOMPSON, EDWINA KAYE (LPC-INTERN)
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:KAYE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 CADILLAC BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-5433
Mailing Address - Country:US
Mailing Address - Phone:817-797-0079
Mailing Address - Fax:
Practice Address - Street 1:3113 S UNIVERSITY DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-5616
Practice Address - Country:US
Practice Address - Phone:817-797-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70417101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional