Healthcare Provider Details

I. General information

NPI: 1760727259
Provider Name (Legal Business Name): BERNICE JEAN THOMPSON MSW,LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9378 OLIVE BLVD SUITE 317
SAINT LOUIS MO
63132-3215
US

IV. Provider business mailing address

9378 OLIVE BLVD SUITE 317
SAINT LOUIS MO
63132-3215
US

V. Phone/Fax

Practice location:
  • Phone: 314-994-9344
  • Fax:
Mailing address:
  • Phone: 314-994-9344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number251V00000X
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number104100000X
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: