Provider Demographics
NPI:1487080487
Name:THOMPSON, KIP VAN (MA)
Entity type:Individual
Prefix:MR
First Name:KIP
Middle Name:VAN
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 TERRACE ST
Mailing Address - Street 2:APT. 314
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2512
Mailing Address - Country:US
Mailing Address - Phone:770-856-6359
Mailing Address - Fax:
Practice Address - Street 1:166 TERRACE ST
Practice Address - Street 2:APT. 314
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2512
Practice Address - Country:US
Practice Address - Phone:770-856-6359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent