Provider Demographics
NPI:1235647470
Name:THOMPSON, LAURIE GAYES (PHD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:GAYES
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:ANNE
Other - Last Name:GAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4942 N WASHTENAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2724
Mailing Address - Country:US
Mailing Address - Phone:413-320-7152
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE # 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009687103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent