=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013324326
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARICIA TONI THOMPSON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2014
-----------------------------------------------------
Last Update Date | 07/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 CAMPUS ROAD
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-247-6631
-----------------------------------------------------
Fax | 718-485-5495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 PUTNAM AVE #3
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11221-4808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-247-6631
-----------------------------------------------------
Fax | 718-485-5495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 091584
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------