Provider Demographics
NPI:1467120006
Name:THOMPSON, ATHENA R
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E SOUTH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2659
Mailing Address - Country:US
Mailing Address - Phone:660-562-4304
Mailing Address - Fax:660-562-4308
Practice Address - Street 1:114 E SOUTH HILLS DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2659
Practice Address - Country:US
Practice Address - Phone:660-562-4304
Practice Address - Fax:660-562-4308
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MO20210342821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021034282OtherCLINICAL SOCIAL WORK