Healthcare Provider Details

I. General information

NPI: 1942681630
Provider Name (Legal Business Name): HEATHER RENEE THORNSBERRY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

IV. Provider business mailing address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

V. Phone/Fax

Practice location:
  • Phone: 313-274-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704308209
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: