Basic Information
| Provider Information | |||||||||
| NPI: | 1023439965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | DELORES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2581 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112072412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184956700 | ||||||||
| FaxNumber: | 7184854018 | ||||||||
| Practice Location | |||||||||
| Address1: | 2581 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184956700 | ||||||||
| FaxNumber: | 7184854018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2013 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 106292 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.