Provider Demographics
NPI:1942735949
Name:THOMPSON, DALANA SUE
Entity type:Individual
Prefix:
First Name:DALANA
Middle Name:SUE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E RIVERPARK LN STE 125
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6661
Mailing Address - Country:US
Mailing Address - Phone:208-794-8758
Mailing Address - Fax:
Practice Address - Street 1:600 E RIVERPARK LN STE 125
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6661
Practice Address - Country:US
Practice Address - Phone:208-254-5450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC6953101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNPI-1922533520Medicaid