Healthcare Provider Details

I. General information

NPI: 1487088316
Provider Name (Legal Business Name): SHAWN R THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S 114TH ST
MILWAUKEE WI
53227-1031
US

IV. Provider business mailing address

2222 S 114TH ST
MILWAUKEE WI
53227-1031
US

V. Phone/Fax

Practice location:
  • Phone: 414-449-4444
  • Fax:
Mailing address:
  • Phone: 414-449-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number2254000000X
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: