1114285814 NPI number — CHARLOS VERNELL THOMPSON LCSW, PHD

Table of content: CHARLOS VERNELL THOMPSON LCSW, PHD (NPI 1114285814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114285814 NPI number — CHARLOS VERNELL THOMPSON LCSW, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
CHARLOS
Provider Middle Name:
VERNELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, PHD
Provider Gender Code:
M

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1114285814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950244
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40295-0244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-218-8926
Provider Business Mailing Address Fax Number:
812-218-8930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 PORTLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40212-1033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-774-8631
Provider Business Practice Location Address Fax Number:
502-996-8309
Provider Enumeration Date:
05/01/2012

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: 1041C0700X , with the licence number:  3534 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 104085 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12731602 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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