Provider Demographics
NPI:1033714308
Name:THORNSEN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THORNSEN
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 1:17307 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1896
Mailing Address - Country:US
Mailing Address - Phone:616-502-3480
Mailing Address - Fax:
Practice Address - Street 1:4565 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2371
Practice Address - Country:US
Practice Address - Phone:616-502-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018817101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health