Provider Demographics
NPI:1780039826
Name:THOMPSON, KYLE DOUGLAS (DPT, LAT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DOUGLAS
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DPT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:1830 HANLEY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9368
Practice Address - Country:US
Practice Address - Phone:715-386-1155
Practice Address - Fax:715-386-1105
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI139582251X0800X
MN10784225100000X
MN26762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer