Provider Demographics
NPI:1124513734
Name:THOMPSON, PHILLIP ANTONIO (MFT)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:ANTONIO
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 E BROADWAY STE 291
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1711
Mailing Address - Country:US
Mailing Address - Phone:502-608-7640
Mailing Address - Fax:
Practice Address - Street 1:3146 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1441
Practice Address - Country:US
Practice Address - Phone:502-776-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist