Provider Demographics
NPI:1902443807
Name:THOMPSON, NICOLE MARIE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
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 1:260 S 4TH ST APT 3E
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5260
Mailing Address - Country:US
Mailing Address - Phone:949-981-9048
Mailing Address - Fax:
Practice Address - Street 1:SOUTHEAST, INC.
Practice Address - Street 2:16 W LONG ST
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215
Practice Address - Country:US
Practice Address - Phone:614-225-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker