Provider Demographics
NPI:1841505997
Name:THOMPSON, AGNES
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6842 SHALLOW RIVER CT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-4193
Mailing Address - Country:US
Mailing Address - Phone:832-704-7494
Mailing Address - Fax:
Practice Address - Street 1:6842 SHALLOW RIVER CT
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-4193
Practice Address - Country:US
Practice Address - Phone:832-704-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18284941171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX18284941OtherTEXAS DRIVERS LICENSE