MEDICARE: SYRETHA RENA THOMPSON

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	171M00000X	Case Manager/Care Coordinator		OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1255994497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYRETHA RENA THOMPSON

Provider Business Mailing Address
First Line	:	4404 HILL AVE APT A201
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-5478
Country	:	US
Telephone Number	:	567-225-8987
Fax Number	:

Provider Business Practice Location Address
First Line	:	4404 HILL AVE APT A201
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-5478
Country	:	US
Telephone Number	:	567-225-8987
Fax Number	:

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

Provider Enumeration Date	:	04/14/2019
Last Update Date	:	06/15/2026

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