Provider Demographics
NPI:1952925182
Name:THOMPSON, MARIAH ANNE (MFT-IT)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ANNE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MFT-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11447 2ND ST STE 9B
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9522
Mailing Address - Country:US
Mailing Address - Phone:815-601-4673
Mailing Address - Fax:866-303-8062
Practice Address - Street 1:11447 2ND ST STE 9B
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9522
Practice Address - Country:US
Practice Address - Phone:815-601-4673
Practice Address - Fax:866-303-8062
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI812-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty