Provider Demographics
NPI:1811469653
Name:THORSON, MATTHEW JON (LADC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JON
Last Name:THORSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11900 WAYZATA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2018
Mailing Address - Country:US
Mailing Address - Phone:612-454-2011
Mailing Address - Fax:952-546-1683
Practice Address - Street 1:11900 WAYZATA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2018
Practice Address - Country:US
Practice Address - Phone:612-454-2011
Practice Address - Fax:952-546-1683
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304783101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)