MEDICARE: MIKAELA L THOMPSON MOT, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	6062	AZ

General Provider Information

NPI Number	:	1306237565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAELA L THOMPSON MOT, OTR/L

Provider Business Mailing Address
First Line	:	19389 N 59TH AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-6500
Country	:	US
Telephone Number	:	623-537-6000
Fax Number	:	623-537-6014

Provider Business Practice Location Address
First Line	:	5815 W UTOPIA ROAD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-5229
Country	:	US
Telephone Number	:	623-537-6000
Fax Number	:	623-537-6014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2015
Last Update Date	:	10/18/2023

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