Provider Demographics
NPI:1245830785
Name:THOMPSON, KEITH MARLEY (BS)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:MARLEY
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6885 B-5 SW 18TH ST.
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433
Mailing Address - Country:US
Mailing Address - Phone:561-271-8768
Mailing Address - Fax:954-425-6411
Practice Address - Street 1:6885 B-5 SW 18TH ST.
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433
Practice Address - Country:US
Practice Address - Phone:561-271-8768
Practice Address - Fax:954-425-6411
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRB7-20-139856106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1083277CCMedicaid