Provider Demographics
NPI:1740751858
Name:THOMPSON, KYLE DON (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DON
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 AMBERLEY PL
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-2005
Mailing Address - Country:US
Mailing Address - Phone:979-574-3674
Mailing Address - Fax:
Practice Address - Street 1:4407 AMBERLEY PL
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-2005
Practice Address - Country:US
Practice Address - Phone:979-574-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT17352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE049902498OtherBOARD OF CERTIFICATION
TXAT1735OtherTEXAS DEPARTMENT OF LICENSURE AND REGULATION