Provider Demographics
NPI:1457112120
Name:THOMSON, IMOGEN (LAC)
Entity type:Individual
Prefix:
First Name:IMOGEN
Middle Name:
Last Name:THOMSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 OVERLOOK AVE
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-2660
Mailing Address - Country:US
Mailing Address - Phone:908-548-5171
Mailing Address - Fax:
Practice Address - Street 1:343 OLD GEORGES RD STE 201
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-4801
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00766000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health