Healthcare Provider Details

I. General information

NPI: 1215004668
Provider Name (Legal Business Name): THOMAS C. THOMPSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W. GRIGGS AVE.
LAS CRUCES NM
88001
US

IV. Provider business mailing address

385 CALLE DE ALEGRA BLDG. A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-647-2800
  • Fax: 575-647-2898
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0003
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number129
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: