Provider Demographics
NPI:1396968061
Name:THOMPSON, SUSAN J (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3301 30TH AVE S STE 101
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6009
Mailing Address - Country:US
Mailing Address - Phone:701-780-9700
Mailing Address - Fax:701-780-9709
Practice Address - Street 1:3301 30TH AVE S STE 101
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6009
Practice Address - Country:US
Practice Address - Phone:701-780-9700
Practice Address - Fax:701-780-9709
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND226103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN715764OtherMEDICARE PART B
ND000016950Medicaid
NDG88124Medicare UPIN