Provider Demographics
NPI:1083177034
Name:THOMPSON, KELLY MARIE (OT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18704 N COOK DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-4499
Mailing Address - Country:US
Mailing Address - Phone:651-343-7971
Mailing Address - Fax:
Practice Address - Street 1:401 S GALLAHER VIEW RD APT 210
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5334
Practice Address - Country:US
Practice Address - Phone:651-343-7971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5330225X00000X
FLOT19912225X00000X
HIOT1870225X00000X
AZ008212225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist