Provider Demographics
NPI:1669930715
Name:THOMPSON, TOMMY (LCPC)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 KARL LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3521
Mailing Address - Country:US
Mailing Address - Phone:217-491-2708
Mailing Address - Fax:
Practice Address - Street 1:4481 ASH GROVE DR STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6359
Practice Address - Country:US
Practice Address - Phone:217-491-2708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36627101YA0400X
IL180013075101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)