Provider Demographics
NPI:1386879187
Name:THOMPSON, ELLYN F (LADAC)
Entity type:Individual
Prefix:MRS
First Name:ELLYN
Middle Name:F
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 CIELO AZUL RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7240
Mailing Address - Country:US
Mailing Address - Phone:505-866-5439
Mailing Address - Fax:
Practice Address - Street 1:79 CIELO AZUL RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7240
Practice Address - Country:US
Practice Address - Phone:505-866-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0088751101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)