Provider Demographics
NPI:1700094802
Name:THOMPSON, SUSAN MARY (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARY
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:827 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3719
Mailing Address - Country:US
Mailing Address - Phone:406-728-9142
Mailing Address - Fax:
Practice Address - Street 1:827 LOCUST ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3719
Practice Address - Country:US
Practice Address - Phone:406-728-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPT 119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0349741Medicaid