Provider Demographics
NPI:1053148668
Name:THOMPSON, DESTINY (DPT)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 E HACIENDA ST
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77418-2827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 ADMIRALTY WAY STE 300
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5444
Practice Address - Country:US
Practice Address - Phone:310-273-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1382529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist