Provider Demographics
NPI:1962717017
Name:THOMPSON, DEREK CHASE (PTA)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:CHASE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 REGIONAL AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:CHAVIES
Mailing Address - State:KY
Mailing Address - Zip Code:41727-8646
Mailing Address - Country:US
Mailing Address - Phone:606-435-8284
Mailing Address - Fax:
Practice Address - Street 1:200 MULBERY STREET SUITE C
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41313
Practice Address - Country:US
Practice Address - Phone:606-593-6003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02681225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant