Healthcare Provider Details

I. General information

NPI: 1114114774
Provider Name (Legal Business Name): JOANNE LOUISE THURSTON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9196 LAKE AVE S
SPICER MN
56288-8619
US

IV. Provider business mailing address

9196 LAKE AVE S
SPICER MN
56288-8619
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5958
  • Fax:
Mailing address:
  • Phone: 320-231-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1317
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: