Provider Demographics
NPI:1528387511
Name:THOMPSON, MICHELLE DESHAWN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DESHAWN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 675982
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30006-0024
Mailing Address - Country:US
Mailing Address - Phone:678-778-4088
Mailing Address - Fax:
Practice Address - Street 1:2169 LAKE PARK DR SE
Practice Address - Street 2:APT O
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8875
Practice Address - Country:US
Practice Address - Phone:678-778-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-31
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist