Healthcare Provider Details

I. General information

NPI: 1932361490
Provider Name (Legal Business Name): GLENDA THORNE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 S JEFFERSON AVE STE B
COVINGTON LA
70433-3169
US

IV. Provider business mailing address

312 S JEFFERSON AVE STE B
COVINGTON LA
70433-3169
US

V. Phone/Fax

Practice location:
  • Phone: 985-246-9508
  • Fax:
Mailing address:
  • Phone: 985-246-9508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number692
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: