Provider Demographics
NPI:1215403316
Name:THORNE, CRYSTAL ANN (BSW)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN
Last Name:THORNE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:ANN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 S UNIVERSITY AVE STE 3200
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-4427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE STE 3200
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$OtherSOCIAL SECURITY