Provider Demographics
NPI:1376612341
Name:THOMPSON, MALISSA (MPT)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 STONE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9233
Mailing Address - Country:US
Mailing Address - Phone:502-387-7783
Mailing Address - Fax:
Practice Address - Street 1:3541 PAOLI PIKE
Practice Address - Street 2:
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119-9751
Practice Address - Country:US
Practice Address - Phone:502-387-7783
Practice Address - Fax:812-941-0198
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004967A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist