Provider Demographics
NPI:1265857734
Name:THOMPSON, CHAD RUSSELL
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:RUSSELL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10806 CAPSTAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-7094
Mailing Address - Country:US
Mailing Address - Phone:813-422-4336
Mailing Address - Fax:
Practice Address - Street 1:7550 43RD ST N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3601
Practice Address - Country:US
Practice Address - Phone:727-824-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL181651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical