Basic Information
| Provider Information | |||||||||
| NPI: | 1134401946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | DONTE | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4510 PERALTA BLVD | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945365755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107133202 | ||||||||
| FaxNumber: | 5107130684 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 PERALTA BLVD | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945365755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107133202 | ||||||||
| FaxNumber: | 5107130684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2011 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RI-T1105241853 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | RI-T1105241853 | 01 | CA | BREINING INSTITUTE | OTHER |