Healthcare Provider Details

I. General information

NPI: 1487080487
Provider Name (Legal Business Name): KIP VAN THOMPSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W 57TH ST STE 1100
NEW YORK NY
10019-2401
US

IV. Provider business mailing address

368 S PICKETT ST UNIT 22141
ALEXANDRIA VA
22304-8322
US

V. Phone/Fax

Practice location:
  • Phone: 770-856-6359
  • Fax:
Mailing address:
  • Phone: 770-856-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number022173
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number022173
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number022173
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: