Provider Demographics
NPI:1043924715
Name:THOMPSON, THAD TYLER (COTA)
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:TYLER
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 FAIRBURY DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-7028
Mailing Address - Country:US
Mailing Address - Phone:843-442-8237
Mailing Address - Fax:
Practice Address - Street 1:3039 OKATIE HWY
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-5101
Practice Address - Country:US
Practice Address - Phone:843-705-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5471225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation