Provider Demographics
NPI:1780009498
Name:THOMPSON, MARK (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 ALAMO ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2186
Mailing Address - Country:US
Mailing Address - Phone:805-522-6577
Mailing Address - Fax:805-210-7271
Practice Address - Street 1:3605 ALAMO ST
Practice Address - Street 2:STE 100
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2186
Practice Address - Country:US
Practice Address - Phone:805-522-6577
Practice Address - Fax:805-210-7271
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8051225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant