Provider Demographics
NPI:1649920901
Name:THOMPSON, BRIAN (PROGRAM MANAGER)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PROGRAM MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E MONROE ST STE 38109
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5713
Mailing Address - Country:US
Mailing Address - Phone:872-243-3847
Mailing Address - Fax:
Practice Address - Street 1:55 E MONROE ST STE 38109
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-5713
Practice Address - Country:US
Practice Address - Phone:872-243-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5894101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor