Healthcare Provider Details

I. General information

NPI: 1144327107
Provider Name (Legal Business Name): PATRICIA M THORN KISH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PATRICIA M THORN LCSW

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SAW MILL RD STE 3103
LAFAYETTE IN
47905-5592
US

IV. Provider business mailing address

2493 GALA DR
WEST LAFAYETTE IN
47906-4839
US

V. Phone/Fax

Practice location:
  • Phone: 765-414-8227
  • Fax:
Mailing address:
  • Phone: 765-414-8227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003983
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: