Provider Demographics
NPI:1144724311
Name:THOMPSON, NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5001
Mailing Address - Country:US
Mailing Address - Phone:919-923-1645
Mailing Address - Fax:
Practice Address - Street 1:15 N LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-5001
Practice Address - Country:US
Practice Address - Phone:919-923-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00015771041C0700X
PACW0196491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical