1851922405 NPI number — LUCY THOMPSON

Table of content: LUCY THOMPSON (NPI 1851922405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851922405 NPI number — LUCY THOMPSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
LUCY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MONTANARO
Provider Other First Name:
LUCY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851922405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776974
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-672-2119
Provider Business Mailing Address Fax Number:
313-432-7759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 CHERRY ST SE STE 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-4607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-8750
Provider Business Practice Location Address Fax Number:
616-685-8002
Provider Enumeration Date:
02/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  4704330108 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1851922405 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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