Healthcare Provider Details

I. General information

NPI: 1013541481
Provider Name (Legal Business Name): MARK THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 PARSONAGE RD
GREENWICH CT
06830-3941
US

IV. Provider business mailing address

528 MUNRO AVE
MAMARONECK NY
10543-3419
US

V. Phone/Fax

Practice location:
  • Phone: 203-618-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number000679
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: