Provider Demographics
NPI:1376200840
Name:THORESON, SAMANTHA GAIL (IADC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAIL
Last Name:THORESON
Suffix:
Gender:F
Credentials:IADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334-0036
Mailing Address - Country:US
Mailing Address - Phone:800-592-0180
Mailing Address - Fax:712-566-5229
Practice Address - Street 1:703 16TH ST
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1623
Practice Address - Country:US
Practice Address - Phone:800-592-0180
Practice Address - Fax:712-566-5229
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303106101YA0400X
IA21R022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)