=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518579564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMPSON COUNSELING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2020
-----------------------------------------------------
Last Update Date | 08/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 N UNION AVE
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-3267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-894-7505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3882
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88202-3882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-489-4750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LCSW
-----------------------------------------------------
Name | MATTHEW THOMPSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 575-489-4750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------