MEDICARE: MS. HEATHER RENEE THORNSBERRY PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704308209	MI

General Provider Information

NPI Number	:	1942681630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HEATHER RENEE THORNSBERRY PMHNP

Provider Business Mailing Address
First Line	:	14799 DIX TOLEDO RD
Second Line	:
City	:	SOUTHGATE
State	:	MI
Zip	:	48195-2507
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14799 DIX TOLEDO RD
Second Line	:
City	:	SOUTHGATE
State	:	MI
Zip	:	48195-2507
Country	:	US
Telephone Number	:	313-274-3700
Fax Number	:

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

Provider Enumeration Date	:	06/18/2015
Last Update Date	:	05/30/2026

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