Healthcare Provider Details

I. General information

NPI: 1417015413
Provider Name (Legal Business Name): MR. KEVIN LEE THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 13TH STREET
LUCERNE CA
95458-8106
US

IV. Provider business mailing address

PO BOX 3371
CLEARLAKE CA
95422-3371
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-7090
  • Fax: 707-994-7096
Mailing address:
  • Phone: 707-350-5536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: