Provider Demographics
NPI:1407539075
Name:THOMPSON, SYDNEY T (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:T
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 BUELL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-3270
Mailing Address - Country:US
Mailing Address - Phone:574-721-9129
Mailing Address - Fax:
Practice Address - Street 1:10106 DUPONT CIRCLE DR E
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1639
Practice Address - Country:US
Practice Address - Phone:260-479-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003238A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer