Provider Demographics
NPI:1902951031
Name:THOMPSON, HERMAN TED (LP)
Entity Type:Individual
Prefix:MR
First Name:HERMAN
Middle Name:TED
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2554
Mailing Address - Country:US
Mailing Address - Phone:612-821-2099
Mailing Address - Fax:612-821-2099
Practice Address - Street 1:1516 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2554
Practice Address - Country:US
Practice Address - Phone:612-821-2099
Practice Address - Fax:612-821-2099
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2769103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist