Provider Demographics
NPI:1053879643
Name:ELLERBUSCH-THOMPSON, KATHY ANN
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:ANN
Last Name:ELLERBUSCH-THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8408 W TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-7632
Mailing Address - Country:US
Mailing Address - Phone:812-480-2252
Mailing Address - Fax:
Practice Address - Street 1:4233 GATEWAY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8900
Practice Address - Country:US
Practice Address - Phone:812-450-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001755A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist