Provider Demographics
NPI:1548095722
Name:THOMPSON, JOHN LEWIS (SUDRC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LEWIS
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E COTATI AVE
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-4442
Mailing Address - Country:US
Mailing Address - Phone:707-795-4336
Mailing Address - Fax:
Practice Address - Street 1:420 E COTATI AVE
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-4442
Practice Address - Country:US
Practice Address - Phone:707-795-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12208101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)