Healthcare Provider Details

I. General information

NPI: 1033778295
Provider Name (Legal Business Name): MITCHELL THOMPSON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 S LOCUST ST
GRAND ISLAND NE
68801-6751
US

IV. Provider business mailing address

PO BOX 5285
GRAND ISLAND NE
68802-5285
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-9700
  • Fax:
Mailing address:
  • Phone: 308-675-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3958
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: