MEDICARE: MS. TAMARA IDETTE THORN DMSC DSW LCSW, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	8654	SC
2	1041C0700X	Clinical Social Worker		NC
3	363AM0700X	Medical Physician Assistant	5697	GA
4	101YA0400X	Addiction (Substance Use Disorder) Counselor		NC
5	363A00000X	Physician Assistant	5697	GA
6	1041C0700X	Clinical Social Worker	C004844	NC
7	101YA0400X	Addiction (Substance Use Disorder) Counselor		GA
8	1041C0700X	Clinical Social Worker	CSW004234	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CSW004234	OTHER	GA	LCSW
2	C004844	OTHER	NC	LCSW
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0010-05760	OTHER	NC	PA
5	5697	OTHER	GA	PA LICENSE

General Provider Information

NPI Number	:	1548320823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TAMARA IDETTE THORN DMSC DSW LCSW, PA-C

Provider Business Mailing Address
First Line	:	PO BOX 2687
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-2687
Country	:	US
Telephone Number	:	704-898-7837
Fax Number	:	912-244-9958

Provider Business Practice Location Address
First Line	:	635 STEPHENSON AVE
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31405-5970
Country	:	US
Telephone Number	:	912-352-2921
Fax Number	:	912-352-1038

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2006
Last Update Date	:	12/17/2025

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