Provider Demographics
NPI:1992157382
Name:THOMPSON, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 BOAT CLUB RD
Mailing Address - Street 2:SUITE#106
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7019
Mailing Address - Country:US
Mailing Address - Phone:817-238-0106
Mailing Address - Fax:817-238-8333
Practice Address - Street 1:4516 BOAT CLUB RD
Practice Address - Street 2:SUITE#106
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7019
Practice Address - Country:US
Practice Address - Phone:817-238-0106
Practice Address - Fax:817-238-8333
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20775032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional