MEDICARE: MR. BRUCE TODD THOMPSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	01194	TX

General Provider Information

NPI Number	:	1194954016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRUCE TODD THOMPSON LCSW

Provider Business Mailing Address
First Line	:	4815 GERONA DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4914
Country	:	US
Telephone Number	:	512-228-8847
Fax Number	:

Provider Business Practice Location Address
First Line	:	4815 GERONA DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4914
Country	:	US
Telephone Number	:	512-228-8847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2009
Last Update Date	:	07/13/2009

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