Healthcare Provider Details

I. General information

NPI: 1801022132
Provider Name (Legal Business Name): TRACY MITCHELL THOMPSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2274 MOUNT MOOSILAUKE HWY
PIKE NH
03780-5615
US

IV. Provider business mailing address

PO BOX 175
HAVERHILL NH
03765-0175
US

V. Phone/Fax

Practice location:
  • Phone: 603-989-3500
  • Fax: 603-989-3169
Mailing address:
  • Phone: 603-989-3500
  • Fax: 603-989-3169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19021
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0091985
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1778
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: