Healthcare Provider Details

I. General information

NPI: 1639853773
Provider Name (Legal Business Name): CAROLYN J THOMPSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 SEVENTH AVE STE 4124
FORT WORTH TX
76104-2733
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-7439
  • Fax: 682-885-1672
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103552
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103552
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: