MEDICARE: SUSAN T THOMPSON LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	6801083539	MI

General Provider Information

NPI Number	:	1912992231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN T THOMPSON LSW

Provider Business Mailing Address
First Line	:	6562 FAWN RIDGE DR
Second Line	:
City	:	VIERA
State	:	FL
Zip	:	32940-6859
Country	:	US
Telephone Number	:	321-255-0743
Fax Number	:

Provider Business Practice Location Address
First Line	:	1381 S PATRICK DR
Second Line	:	45TH MEDICAL GROUP
City	:	PATRICK AFB
State	:	FL
Zip	:	32925-3606
Country	:	US
Telephone Number	:	321-494-8234
Fax Number	:	321-494-1378

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/08/2007

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