Healthcare Provider Details

I. General information

NPI: 1881794642
Provider Name (Legal Business Name): PAMELA JEAN THOMPSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 1/2 NEBRASKA AVE.
BRECKENRIDGE MN
56520
US

IV. Provider business mailing address

682 WYNDEMERE DR
WEST FARGO ND
58078-4036
US

V. Phone/Fax

Practice location:
  • Phone: 218-643-9330
  • Fax: 218-643-9330
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW 6408
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: