Provider Demographics
NPI:1346414331
Name:THOMPSON, KELLY L (MSW, LSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 WISHARD BLVD
Mailing Address - Street 2:INFECTIOUS DISEASE CLINIC
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 WISHARD BLVD
Practice Address - Street 2:INFECTIOUS DISEASE CLINIC
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-630-6612
Practice Address - Fax:317-656-4035
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005328A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200542360Medicaid