Provider Demographics
NPI:1780405852
Name:THOMPSON, DEMETRIOUS
Entity type:Individual
Prefix:
First Name:DEMETRIOUS
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 N PORTAGE PATH
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-5861
Mailing Address - Country:US
Mailing Address - Phone:980-423-9568
Mailing Address - Fax:
Practice Address - Street 1:1336 N PORTAGE PATH
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5861
Practice Address - Country:US
Practice Address - Phone:980-423-9568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT390668101YA0400X, 101YM0800X, 171W00000X, 3747P1801X, 172A00000X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant