Basic Information
| Provider Information | |||||||||
| NPI: | 1124190046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | KIMBERLEY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | ELLSWORTH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540110670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152736770 | ||||||||
| FaxNumber: | 7152736862 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 DERONDA ST | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6956-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | HP69910 | 01 | MN | HEALTHPARTNERS | OTHER | 920461025361 | 01 | MN | PREFERRED ONE | OTHER | 99F89TH | 01 | MN | BLUECROSS BLUESHIELD | OTHER | 43585400 | 05 | WI | MEDICAID |