Provider Demographics
NPI:1780954339
Name:THOMPSON, MARISA MAE (MA, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:MAE
Last Name:THOMPSON
Suffix:
Gender:
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:MAE
Other - Last Name:GRUNKLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7425 LA VISTA DR APT 905
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-4220
Mailing Address - Country:US
Mailing Address - Phone:507-202-3227
Mailing Address - Fax:
Practice Address - Street 1:1881 SYLVAN AVE STE 150
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2002
Practice Address - Country:US
Practice Address - Phone:214-743-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3297225XP0200X
MT6152225XP0200X
TX124389225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics