Provider Demographics
NPI:1245987858
Name:THOMPSON, MARYGRACE (LVN)
Entity type:Individual
Prefix:MRS
First Name:MARYGRACE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33942 NASTURTIUM LN
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-3431
Mailing Address - Country:US
Mailing Address - Phone:760-459-9540
Mailing Address - Fax:
Practice Address - Street 1:31630 RAILROAD CANYON RD STE 2A
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-9478
Practice Address - Country:US
Practice Address - Phone:760-417-5927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health