Provider Demographics
NPI:1780800573
Name:THOMPSON, ANDREA J (LICSW)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:ANDREA
Other - Middle Name:J
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:31 HEATH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1650
Mailing Address - Country:US
Mailing Address - Phone:617-523-6400
Mailing Address - Fax:617-622-1086
Practice Address - Street 1:31 HEATH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1650
Practice Address - Country:US
Practice Address - Phone:617-523-6400
Practice Address - Fax:617-622-1086
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1138841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303414Medicaid