Provider Demographics
NPI:1043605165
Name:THORNBURGH, ANDREW NICHOLAS (BS, BCABA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:NICHOLAS
Last Name:THORNBURGH
Suffix:
Gender:M
Credentials:BS, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12305 NOREAST LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12305 NOREAST LAKE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4040
Practice Address - Country:US
Practice Address - Phone:813-766-4806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-15-6479103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst