Healthcare Provider Details

I. General information

NPI: 1831662345
Provider Name (Legal Business Name): NISHELLE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 S 5TH ST STE 306
SAINT CHARLES MO
63301-2447
US

IV. Provider business mailing address

10417 WILLOWDALE DR
SAINT LOUIS MO
63146-5619
US

V. Phone/Fax

Practice location:
  • Phone: 314-422-8716
  • Fax: 636-493-1884
Mailing address:
  • Phone: 314-422-8716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2018043841
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: