Provider Demographics
NPI:1629079264
Name:THOMPSON, KATHERINE LEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:LEE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6717 E 2ND ST
Mailing Address - Street 2:STE D
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2659
Mailing Address - Country:US
Mailing Address - Phone:928-771-3560
Mailing Address - Fax:928-771-3542
Practice Address - Street 1:6717 E 2ND ST
Practice Address - Street 2:STE D
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2659
Practice Address - Country:US
Practice Address - Phone:928-771-3560
Practice Address - Fax:928-771-3542
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ820078Medicaid
77922Medicare ID - Type Unspecified