Healthcare Provider Details

I. General information

NPI: 1629639844
Provider Name (Legal Business Name): LEGGER THOMAS THOMPSON JR. 17131 EXP 1-10-25
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4759 E OLIVE AVE STE 102
FRESNO CA
93702-1700
US

IV. Provider business mailing address

2072 N MARKS AVE APT 101
FRESNO CA
93722-6512
US

V. Phone/Fax

Practice location:
  • Phone: 559-538-0251
  • Fax:
Mailing address:
  • Phone: 559-538-0251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDCR17131
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: