Provider Demographics
NPI:1720805864
Name:THOMPSON, KIM (LAC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:THOMPSON
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 1:1515 W BELL ST
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-3240
Mailing Address - Country:US
Mailing Address - Phone:406-815-5831
Mailing Address - Fax:833-314-0429
Practice Address - Street 1:1515 W BELL ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-3240
Practice Address - Country:US
Practice Address - Phone:406-815-5831
Practice Address - Fax:833-314-0429
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-72373101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)