Basic Information
| Provider Information | |||||||||
| NPI: | 1770086951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
| FaxNumber: | 6164866702 | ||||||||
| Practice Location | |||||||||
| Address1: | 4069 LAKE DR SE STE 114 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495468816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162678346 | ||||||||
| FaxNumber: | 6162678004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2018 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501006940 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.