Provider Demographics
NPI:1619335312
Name:THOMPSON, KIMBERLY (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BOSAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:1A C ST W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-5409
Mailing Address - Country:US
Mailing Address - Phone:843-327-3543
Mailing Address - Fax:
Practice Address - Street 1:5423 HAMILTON WOLFE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4344
Practice Address - Country:US
Practice Address - Phone:210-694-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213602224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant