Provider Demographics
NPI:1205418605
Name:THOMPSON, CARLEY
Entity Type:Individual
Prefix:
First Name:CARLEY
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 1:6659 E VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-4339
Mailing Address - Country:US
Mailing Address - Phone:480-278-5073
Mailing Address - Fax:
Practice Address - Street 1:6659 E VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-4339
Practice Address - Country:US
Practice Address - Phone:480-278-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA12993235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist