Provider Demographics
NPI:1063452308
Name:THOMPSON, KRISTEN R (LPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9684 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-2754
Mailing Address - Country:US
Mailing Address - Phone:618-566-8160
Mailing Address - Fax:
Practice Address - Street 1:10607 LINCOLN TRL
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1913
Practice Address - Country:US
Practice Address - Phone:618-310-1600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ43283Medicare UPIN
ILK24621/212900Medicare ID - Type UnspecifiedWELLNESSONE OF EB
ILK24429/212876Medicare ID - Type UnspecifiedWELLNESSONE OF CV
ILK24494/212885Medicare ID - Type UnspecifiedWELLNESSONE OF FH