Provider Demographics
NPI:1104891779
Name:THOMPSON, MARY KATHRYN (PMHNP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:LIPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 3808
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3808
Mailing Address - Country:US
Mailing Address - Phone:503-413-5089
Mailing Address - Fax:503-413-1860
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 345
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-413-7513
Practice Address - Fax:503-413-7503
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000030387N1363LF0000X
OR200550127NP363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027956Medicaid
ORP36921Medicare UPIN
OR139451Medicare PIN