Healthcare Provider Details
I. General information
NPI: 1548320823
Provider Name (Legal Business Name): TAMARA IDETTE THORN DMSC DSW LCSW, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y
II. Dates (important events)
Enumeration Date: 12/09/2006
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:
III. Provider practice location address
635 STEPHENSON AVE
SAVANNAH GA
31405-5970
US
IV. Provider business mailing address
PO BOX 2687
RICHMOND HILL GA
31324-2687
US
V. Phone/Fax
- Phone: 912-352-2921
- Fax: 912-352-1038
- Phone: 704-898-7837
- Fax: 912-244-9958
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 1041C0700X |
| Taxonomy | Clinical Social Worker |
| License Number | 8654 |
| License Number State | SC |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 1041C0700X |
| Taxonomy | Clinical Social Worker |
| License Number | |
| License Number State | NC |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 363AM0700X |
| Taxonomy | Medical Physician Assistant |
| License Number | 5697 |
| License Number State | GA |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 101YA0400X |
| Taxonomy | Addiction (Substance Use Disorder) Counselor |
| License Number | |
| License Number State | NC |
| # 5 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 363A00000X |
| Taxonomy | Physician Assistant |
| License Number | 5697 |
| License Number State | GA |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 1041C0700X |
| Taxonomy | Clinical Social Worker |
| License Number | C004844 |
| License Number State | NC |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 101YA0400X |
| Taxonomy | Addiction (Substance Use Disorder) Counselor |
| License Number | |
| License Number State | GA |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 1041C0700X |
| Taxonomy | Clinical Social Worker |
| License Number | CSW004234 |
| License Number State | GA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | CSW004234 |
| Identifier Type | OTHER |
| Identifier State | GA |
| Identifier Issuer | LCSW |
| # 2 | |
| Identifier | C004844 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | LCSW |
| # 3 | |
| Identifier | 6003179 |
| Identifier Type | MEDICAID |
| Identifier State | NC |
| Identifier Issuer | |
| # 4 | |
| Identifier | 0010-05760 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | PA |
| # 5 | |
| Identifier | 5697 |
| Identifier Type | OTHER |
| Identifier State | GA |
| Identifier Issuer | PA LICENSE |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
