Provider Demographics
NPI:1427364017
Name:THOMPSON, RONISE TAMARA
Entity type:Individual
Prefix:
First Name:RONISE
Middle Name:TAMARA
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W 33RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3863
Mailing Address - Country:US
Mailing Address - Phone:405-216-5608
Mailing Address - Fax:
Practice Address - Street 1:1717 W 33RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3863
Practice Address - Country:US
Practice Address - Phone:405-216-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123000AMedicaid