=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629101944
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL JEFFREY THOMPSON MA LPC, LBSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 08/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 E SANILAC RD
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48471-1383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-583-0452
-----------------------------------------------------
Fax | 810-648-0315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2333 MARLETTE RD.
-----------------------------------------------------
City | APPLEGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48401-9739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-404-8524
-----------------------------------------------------
Fax | 888-828-8290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 6401009076
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------