Healthcare Provider Details

I. General information

NPI: 1659617876
Provider Name (Legal Business Name): HOLLY SHANNON THOMPSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 S HARVARD AVE SUITE 101
TULSA OK
74135-1812
US

IV. Provider business mailing address

3007 S BOSTON CT
TULSA OK
74114-5216
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-3737
  • Fax: 918-743-8833
Mailing address:
  • Phone: 918-293-0631
  • Fax: 918-293-0631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2788
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: