Provider Demographics
NPI:1003309550
Name:THACKERAY, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:THACKERAY
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 1:2725 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-3134
Mailing Address - Country:US
Mailing Address - Phone:406-262-4987
Mailing Address - Fax:406-791-5994
Practice Address - Street 1:1301 20TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4934
Practice Address - Country:US
Practice Address - Phone:406-262-4987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer