=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184882763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT THOMSON MA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2008
-----------------------------------------------------
Last Update Date | 05/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 TULANE DR SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-280-4351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 CAMINO DEL BOSQUE NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-898-6476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MR. ROBERT D THOMSON
-----------------------------------------------------
Credential | M.A., LPCC
-----------------------------------------------------
Telephone | 505-280-4351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 0484
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------