Healthcare Provider Details

I. General information

NPI: 1700123023
Provider Name (Legal Business Name): JOHNY L THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 AVENUE 64
PASADENA CA
91105-2711
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105-2711
US

V. Phone/Fax

Practice location:
  • Phone: 323-254-2274
  • Fax:
Mailing address:
  • Phone: 323-254-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF73436
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: