MEDICARE: DR. NOAH THORNE PSYD

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1700604360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NOAH THORNE PSYD

Provider Business Mailing Address
First Line	:	1157 W LUNT AVE APT 257
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-3533
Country	:	US
Telephone Number	:	920-471-2928
Fax Number	:

Provider Business Practice Location Address
First Line	:	4422 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5803
Country	:	US
Telephone Number	:	850-621-2340
Fax Number	:

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

Provider Enumeration Date	:	10/01/2024
Last Update Date	:	10/01/2024

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