Provider Demographics
NPI:1679514244
Name:THORN, ELIZABETH (LPC-MH LMFT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:THORN
Suffix:
Gender:F
Credentials:LPC-MH LMFT
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:JETSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC-MH LMFT
Mailing Address - Street 1:1301 WEST OMAHA ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-716-9944
Mailing Address - Fax:605-718-0413
Practice Address - Street 1:1301 WEST OMAHA ST
Practice Address - Street 2:SUITE 220
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-716-9944
Practice Address - Fax:605-718-0413
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH2097101Y00000X, 101YP2500X, 101YM0800X
SDLMFT1072106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575740Medicaid