Provider Demographics
NPI:1992774012
Name:THOMPSON, LISA M (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:THOMPSON
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 1:1319 W HAVENS ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-4116
Mailing Address - Country:US
Mailing Address - Phone:605-996-4778
Mailing Address - Fax:605-996-3660
Practice Address - Street 1:1319 W HAVENS AVE
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-4116
Practice Address - Country:US
Practice Address - Phone:605-996-4778
Practice Address - Fax:605-996-3660
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5833310Medicaid
4997332OtherBXBS OF SD
4997332OtherBXBS OF SD