Basic Information
| Provider Information | |||||||||
| NPI: | 1801141247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | DEBRA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSE | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | DEBRA | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 121 LUPE AVE | ||||||||
| Address2: | |||||||||
| City: | NEWBURY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913203227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055586537 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2055 SAVIERS RD | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930333608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054832253 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2012 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/23/2022 | ||||||||
| NPIReactivationDate: | 03/14/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.