Provider Demographics
NPI:1740314574
Name:THORN, KIPP JAMES (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIPP
Middle Name:JAMES
Last Name:THORN
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 1:1950 S SUNWEST LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-0019
Mailing Address - Country:US
Mailing Address - Phone:909-543-5854
Mailing Address - Fax:
Practice Address - Street 1:1950 S SUNWEST LN
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-0019
Practice Address - Country:US
Practice Address - Phone:909-543-5854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17610103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical