Healthcare Provider Details

I. General information

NPI: 1033714308
Provider Name (Legal Business Name): MARY THORNSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CASCADE WEST PKWY SE
GRAND RAPIDS MI
49546-2164
US

IV. Provider business mailing address

17307 FRANKLIN AVE
SPRING LAKE MI
49456-1896
US

V. Phone/Fax

Practice location:
  • Phone: 616-502-3480
  • Fax:
Mailing address:
  • Phone: 616-502-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401018817
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401018817
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: