Provider Demographics
NPI:1336259365
Name:THOMPSON, LAURANCE (MS)
Entity Type:Individual
Prefix:MR
First Name:LAURANCE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2559 EAGLE PEAK RD
Mailing Address - Street 2:
Mailing Address - City:WEST BROOKFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05060-9794
Mailing Address - Country:US
Mailing Address - Phone:802-272-5919
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD STE 1-6
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9000
Practice Address - Country:US
Practice Address - Phone:802-272-5919
Practice Address - Fax:802-223-7444
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-00062103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010122Medicaid