Provider Demographics
NPI:1225258759
Name:THORSTAD, EILEEN LOUISE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:LOUISE
Last Name:THORSTAD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 S EL MARINO CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-5416
Mailing Address - Country:US
Mailing Address - Phone:480-897-8324
Mailing Address - Fax:
Practice Address - Street 1:455 N 3RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-3924
Practice Address - Country:US
Practice Address - Phone:602-528-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0398171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor