Healthcare Provider Details

I. General information

NPI: 1770930463
Provider Name (Legal Business Name): DONALD THORSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 WATERBURY FALLS DR
O FALLON MO
63368-2202
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 636-336-0297
  • Fax:
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2016017355
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: