Provider Demographics
NPI:1902123987
Name:THOMPSON, KEVIN E (LPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:E
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8261 OLD TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6806
Mailing Address - Country:US
Mailing Address - Phone:540-774-8258
Mailing Address - Fax:
Practice Address - Street 1:8261 OLD TAVERN RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-6806
Practice Address - Country:US
Practice Address - Phone:540-774-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004805101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437137734Medicaid