Provider Demographics
NPI:1265056956
Name:THOMPSON, CONNIE M (CASAC-G)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CASAC-G
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:HOGANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13655
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:518-358-9175
Practice Address - Street 1:404 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:HOGANSBURG
Practice Address - State:NY
Practice Address - Zip Code:13655
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:518-358-9175
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7733OtherCASAC-G