Provider Demographics
NPI:1508431347
Name:THOMSEN, MARY KATHRYN (MS, CF-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:THOMSEN
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-6804
Mailing Address - Country:US
Mailing Address - Phone:601-818-0415
Mailing Address - Fax:
Practice Address - Street 1:4100 S FERDON BLVD STE A1
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5287
Practice Address - Country:US
Practice Address - Phone:850-682-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR201412235Z00000X
FLSZ10396235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist