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General NPI Number Information
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NPI Number | 1215440532
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Entity Type | Individual
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Provider Name | THEODORE THOMPSON JR. LCSW, PHD
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Gender | Male
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Dates
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Enumeration Date | 11/08/2017
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Last Update Date | 02/15/2022
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Provider Practice Location Address
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Address Line | 404 W BOUGHTON RD STE B
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City | BOLINGBROOK
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State | IL
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Zip | 60440-1898
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Country | US
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Telephone | 630-685-4053
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Fax | 630-596-1478
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Provider Business Mailing Address
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Address Line | 404 W BOUGHTON RD STE B
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City | BOLINGBROOK
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State | IL
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Zip | 60440-1898
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Country | US
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Telephone | 630-685-4053
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 149005238
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149005238
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License Number State | IL
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