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: 06/22/2026
Certification Date: 06/22/2026
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

Practice location:
  • Phone: 912-352-2921
  • Fax: 912-352-1038
Mailing address:
  • Phone: 704-898-7837
  • Fax: 912-244-9958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5697
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: