=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124190046
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLEY D THOMPSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 DERONDA ST
-----------------------------------------------------
City | AMERY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54001-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-268-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 670
-----------------------------------------------------
City | ELLSWORTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54011-0670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-273-6770
-----------------------------------------------------
Fax | 715-273-6862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6956-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------