Basic Information
| Provider Information | |||||||||
| NPI: | 1467832857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | NEDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | B.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRUEGER | ||||||||
| OtherFirstName: | NEDRA | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.S. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 N MISSION ST | ||||||||
| Address2: | |||||||||
| City: | OKMULGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744473909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187581930 | ||||||||
| FaxNumber: | 9187581920 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N MISSION ST | ||||||||
| Address2: | |||||||||
| City: | OKMULGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744473909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187581930 | ||||||||
| FaxNumber: | 9187581920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | T080598178 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.