Healthcare Provider Details

I. General information

NPI: 1093446429
Provider Name (Legal Business Name): BRYCE THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 WRIGHT ST
MARQUETTE MI
49855-1955
US

IV. Provider business mailing address

97 S 4TH ST STE B
ISHPEMING MI
49849-2168
US

V. Phone/Fax

Practice location:
  • Phone: 906-228-7611
  • Fax:
Mailing address:
  • Phone: 906-228-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: