Provider Demographics
NPI:1275049769
Name:THORN, ZOE SARAH
Entity Type:Individual
Prefix:
First Name:ZOE
Middle Name:SARAH
Last Name:THORN
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 1:4901 N SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-3511
Mailing Address - Country:US
Mailing Address - Phone:810-785-4324
Mailing Address - Fax:810-785-4485
Practice Address - Street 1:4901 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-3511
Practice Address - Country:US
Practice Address - Phone:810-785-4324
Practice Address - Fax:810-785-4485
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM250389333320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities