Provider Demographics
NPI:1104156173
Name:THOMPSON, KATHERINE COURTNEY (MACCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:COURTNEY
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:COURTNEY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4113 BURWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-3368
Mailing Address - Country:US
Mailing Address - Phone:301-332-3101
Mailing Address - Fax:
Practice Address - Street 1:3600 ANGLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106
Practice Address - Country:US
Practice Address - Phone:817-624-6164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MD235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist