MEDICARE: KELLY THOMPSON

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	221700000X	Art Therapist

General Provider Information

NPI Number	:	1326681479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY THOMPSON

Provider Business Mailing Address
First Line	:	1512 HICKORY CT
Second Line	:
City	:	PORT WASHINGTON
State	:	WI
Zip	:	53074-2403
Country	:	US
Telephone Number	:	262-388-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	534 E GREEN BAY AVE
Second Line	:
City	:	SAUKVILLE
State	:	WI
Zip	:	53080-2012
Country	:	US
Telephone Number	:	262-388-3700
Fax Number	:

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

Provider Enumeration Date	:	10/22/2019
Last Update Date	:	10/22/2019

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Directions to “ KELLY THOMPSON ” Practice Location

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