=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588824478
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE JANE THOMPSON PMHNP-BC,LCSW, LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2008
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8430 MEDICAL PLAZA DR STE 300
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-9758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-910-6142
-----------------------------------------------------
Fax | 980-422-0106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1914 J N PEASE PL
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-4504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-754-8718
-----------------------------------------------------
Fax | 704-803-5923
-----------------------------------------------------
=====================================================
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 | 076873
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11908
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 114912
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 53948
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C013102
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 5018004
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------