Provider Demographics
NPI:1215817051
Name:THOMPSON, GRANT M (LPC-IT)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 PRAIRIE CREEK BLVD UNIT 209
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-8685
Mailing Address - Country:US
Mailing Address - Phone:608-302-6395
Mailing Address - Fax:
Practice Address - Street 1:1225 PRAIRIE CREEK BLVD UNIT 209
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-8685
Practice Address - Country:US
Practice Address - Phone:608-302-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8671-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional