Healthcare Provider Details

I. General information

NPI: 1902002165
Provider Name (Legal Business Name): MS. KISHA THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

IV. Provider business mailing address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

V. Phone/Fax

Practice location:
  • Phone: 213-238-2481
  • Fax: 310-669-9501
Mailing address:
  • Phone: 213-238-2481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number66249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: