MEDICARE: MRS. THERESA A THOMPSON CCC-SLP

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	235Z00000X	Speech-Language Pathologist	01117135	MI

General Provider Information

NPI Number	:	1255600755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA A THOMPSON CCC-SLP

Provider Business Mailing Address
First Line	:	9062 W OAK LN
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-8062
Country	:	US
Telephone Number	:	231-839-0083
Fax Number	:

Provider Business Practice Location Address
First Line	:	9062 W OAK LN
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-8062
Country	:	US
Telephone Number	:	231-839-0083
Fax Number	:

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

Provider Enumeration Date	:	12/29/2011
Last Update Date	:	12/29/2011

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Directions to “ MRS. THERESA A THOMPSON CCC-SLP” Practice Location

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