Provider Demographics
NPI:1336249556
Name:THOMPSON-PURNELL, TAUNDRA LAFAYE (IMH 4934)
Entity Type:Individual
Prefix:MS
First Name:TAUNDRA
Middle Name:LAFAYE
Last Name:THOMPSON-PURNELL
Suffix:
Gender:F
Credentials:IMH 4934
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10219 EASTERN LAKE AVE
Mailing Address - Street 2:102
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-5846
Mailing Address - Country:US
Mailing Address - Phone:407-657-8658
Mailing Address - Fax:407-657-9687
Practice Address - Street 1:10219 EASTERN LAKE AVE
Practice Address - Street 2:102
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-5846
Practice Address - Country:US
Practice Address - Phone:407-657-8658
Practice Address - Fax:407-657-9687
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH4934101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL201033108OtherEIN