Provider Demographics
NPI:1629406244
Name:THOMPSON, ANNELISE R (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANNELISE
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1602
Mailing Address - Country:US
Mailing Address - Phone:631-241-5659
Mailing Address - Fax:
Practice Address - Street 1:1 BRANDYWINE DR
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5721
Practice Address - Country:US
Practice Address - Phone:631-392-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP91033225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics