Provider Demographics
NPI:1609381490
Name:THOMPSON, COLBY WAYNE
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:WAYNE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3283 W JORDAN LINE PKWY APT 223
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-7965
Mailing Address - Country:US
Mailing Address - Phone:719-469-1577
Mailing Address - Fax:
Practice Address - Street 1:14787 S ACADEMY PKWY
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-2077
Practice Address - Country:US
Practice Address - Phone:801-935-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-03
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12565346-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer