Provider Demographics
NPI:1881794642
Name:THOMPSON, PAMELA JEAN (LICSW)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 WYNDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-4036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 1/2 NEBRASKA AVE.
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520
Practice Address - Country:US
Practice Address - Phone:218-643-9330
Practice Address - Fax:218-643-9330
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW 64081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHFPIN:94954OtherHEALTH PARTNERS
MN156635100Medicaid
MN1007124OtherPREFERRED ONE
NDTHO22688OtherBCBS ND
MN067L5THOtherBCBS MN