Provider Demographics
NPI:1811127251
Name:THOMPSON IYAMAH, MICHELLE LEA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LEA
Last Name:THOMPSON IYAMAH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:LEA
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:9541 S WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1113
Mailing Address - Country:US
Mailing Address - Phone:708-203-5265
Mailing Address - Fax:
Practice Address - Street 1:1233 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3255
Practice Address - Country:US
Practice Address - Phone:414-302-1233
Practice Address - Fax:414-306-2922
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004708103T00000X
WI2659057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist