Provider Demographics
NPI:1396371860
Name:THOMPSON, MARCELLA ALICE
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:ALICE
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 1:5516 OVERBROOK WOODS PL APT 103
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-5436
Mailing Address - Country:US
Mailing Address - Phone:502-356-2815
Mailing Address - Fax:
Practice Address - Street 1:5516 OVERBROOK WOODS PL APT 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-5436
Practice Address - Country:US
Practice Address - Phone:502-356-2815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY248360225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0157786384OtherCBI -COMMUNITY BUSINESS IDENTIFIER