Provider Demographics
NPI:1326681479
Name:THOMPSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:1512 HICKORY CT
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2403
Mailing Address - Country:US
Mailing Address - Phone:262-388-3700
Mailing Address - Fax:
Practice Address - Street 1:534 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2012
Practice Address - Country:US
Practice Address - Phone:262-388-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist