Healthcare Provider Details

I. General information

NPI: 1477668465
Provider Name (Legal Business Name): THOMAS RUSSELL THOMPSON MS, MDIV, BCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

2191 ROCKBRIDGE RD
STONE MOUNTAIN GA
30087-3588
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-329-2235
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: