Healthcare Provider Details

I. General information

NPI: 1609942929
Provider Name (Legal Business Name): J. GRAHAM THOMPSON LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S 5TH ST
SPRINGFIELD IL
62703-2312
US

IV. Provider business mailing address

1020 S 5TH ST
SPRINGFIELD IL
62703-2312
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-3143
  • Fax: 217-544-4436
Mailing address:
  • Phone: 217-544-3143
  • Fax: 217-544-4436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166-000115
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: