Provider Demographics
NPI:1962974774
Name:THOMPSON, CHARLENE (BA)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E MICHIGAN AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-5167
Mailing Address - Country:US
Mailing Address - Phone:773-790-5676
Mailing Address - Fax:
Practice Address - Street 1:102 E MAIN ST STE 403
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2744
Practice Address - Country:US
Practice Address - Phone:217-305-6063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNONE