Healthcare Provider Details

I. General information

NPI: 1952191983
Provider Name (Legal Business Name): SHAYNA LYN MIKA THOMPSON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAYNA LYN MIKA THACKER BSW, LSW

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7495 FERNWAY DR
ROANOKE VA
24018-5824
US

IV. Provider business mailing address

7495 FERNWAY DR
ROANOKE VA
24018-5824
US

V. Phone/Fax

Practice location:
  • Phone: 540-577-3412
  • Fax:
Mailing address:
  • Phone: 540-577-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904018190
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00947211
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number259992
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: