Provider Demographics
NPI:1295887487
Name:SIVERSON, THOMPSON (LCPC)
Entity type:Individual
Prefix:
First Name:THOMPSON
Middle Name:
Last Name:SIVERSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10792 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1329
Mailing Address - Country:US
Mailing Address - Phone:208-375-7777
Mailing Address - Fax:208-323-9070
Practice Address - Street 1:10792 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1329
Practice Address - Country:US
Practice Address - Phone:208-375-7777
Practice Address - Fax:208-323-9070
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ4392OtherBLUE CROSS OF IDAHO
ID000010017011OtherREGENCE BLUE SHIELD