Provider Demographics
NPI:1982617593
Name:THOMPSON, MARY SUSAN (MPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5833 W I 20
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1057
Mailing Address - Country:US
Mailing Address - Phone:817-516-1115
Mailing Address - Fax:817-516-1104
Practice Address - Street 1:5833 W I 20
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017
Practice Address - Country:US
Practice Address - Phone:817-516-1115
Practice Address - Fax:817-516-1104
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166410174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676521Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER