Provider Demographics
NPI:1912127119
Name:THOMPSON WILL, DIANE L (PT)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:L
Last Name:THOMPSON WILL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W LEXINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1423
Mailing Address - Country:US
Mailing Address - Phone:859-583-4536
Mailing Address - Fax:859-236-8537
Practice Address - Street 1:409 N STEWARTS LANE
Practice Address - Street 2:WILDERNESS TRACE CHILD DEV CENTER
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1423
Practice Address - Country:US
Practice Address - Phone:859-236-0878
Practice Address - Fax:859-236-0878
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist