Healthcare Provider Details

I. General information

NPI: 1487047528
Provider Name (Legal Business Name): ATHINA THORSON PT, DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ATHINA AJAZI

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N 16TH ST APT 445
PHOENIX AZ
85016-4448
US

IV. Provider business mailing address

313 CHESNEY DR
SUGAR GROVE IL
60554-2238
US

V. Phone/Fax

Practice location:
  • Phone: 630-990-0108
  • Fax:
Mailing address:
  • Phone: 630-999-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-30892
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: