Provider Demographics
NPI:1912780552
Name:THOMPSON, KELSEY MARIE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
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 1:3313 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611
Mailing Address - Country:US
Mailing Address - Phone:559-907-8308
Mailing Address - Fax:
Practice Address - Street 1:1752 E BULLARD AVE, UNIT 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-970-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-23-272208106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty