Provider Demographics
NPI:1699187906
Name:THORESON, LAURA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:THORESON
Suffix:
Gender:F
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:PO BOX 2631
Mailing Address - Street 2:
Mailing Address - City:GUASTI
Mailing Address - State:CA
Mailing Address - Zip Code:91743-2631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 4TH ST APT G301
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0908
Practice Address - Country:US
Practice Address - Phone:626-688-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26374103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical