Provider Demographics
NPI:1306683487
Name:THOMPSON, BRENT THOMAS
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 NW 5TH WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6112
Mailing Address - Country:US
Mailing Address - Phone:888-754-0396
Mailing Address - Fax:
Practice Address - Street 1:6140 W EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-4499
Practice Address - Country:US
Practice Address - Phone:888-754-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician