Provider Demographics
NPI:1770086951
Name:THOMPSON, KELLI JO (MSPT)
Entity type:Individual
Prefix:MS
First Name:KELLI
Middle Name:JO
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:4069 LAKE DR SE STE 114
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-267-8346
Practice Address - Fax:616-267-8004
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist