Provider Demographics
NPI:1356303556
Name:THORNSEN, DAVID E (PSYD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:THORNSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CASCADE WEST PKWY SE STE 240
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2166
Mailing Address - Country:US
Mailing Address - Phone:616-591-9000
Mailing Address - Fax:616-591-9004
Practice Address - Street 1:500 CASCADE WEST PKWY SE STE 240
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2166
Practice Address - Country:US
Practice Address - Phone:616-591-9000
Practice Address - Fax:616-591-9004
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012067103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680D114760OtherBCBS OF MICHIGAN