Provider Demographics
NPI:1861069106
Name:THOMPSON, GINA (RBT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 BRAMBLETON AVE STE 201A
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6527
Mailing Address - Country:US
Mailing Address - Phone:540-291-7480
Mailing Address - Fax:
Practice Address - Street 1:2820 WATERFORD LAKE DR STE 102
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3994
Practice Address - Country:US
Practice Address - Phone:804-895-4678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-16-17639106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty