Provider Demographics
NPI:1922132695
Name:THORN, MICIA RENEE
Entity Type:Individual
Prefix:
First Name:MICIA
Middle Name:RENEE
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 1:3008 EASTPARK DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-6542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 N GLENVILLE DR
Practice Address - Street 2:SUITE 800
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-7207
Practice Address - Country:US
Practice Address - Phone:972-238-9916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111779225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist