Healthcare Provider Details

I. General information

NPI: 1902849839
Provider Name (Legal Business Name): CAROL A THOMPSON MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 CHESTERFIELD ROAD
EAST LYME CT
06333
US

IV. Provider business mailing address

PO BOX 94 29 CHESTERFIELD ROAD
EAST LYME CT
06333-0094
US

V. Phone/Fax

Practice location:
  • Phone: 860-739-6974
  • Fax: 860-739-5290
Mailing address:
  • Phone: 860-739-6974
  • Fax: 860-739-5290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000361
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: