Provider Demographics
NPI:1275371049
Name:THOMPSON, GERVON R (PMHNP)
Entity type:Individual
Prefix:
First Name:GERVON
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 RALPH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5416
Mailing Address - Country:US
Mailing Address - Phone:718-444-0092
Mailing Address - Fax:
Practice Address - Street 1:198 E 121ST ST # 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3523
Practice Address - Country:US
Practice Address - Phone:212-801-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF406088-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health