Provider Demographics
NPI:1083304976
Name:THOMPSON, MATTIE
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:THOMPSON
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 1:1129 S ATLANTA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-3942
Mailing Address - Country:US
Mailing Address - Phone:918-688-0299
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCF521235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist