Provider Demographics
NPI:1144327107
Name:THORN KISH, PATRICIA M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:M
Last Name:THORN KISH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:PATRICIA
Other - Middle Name:M
Other - Last Name:THORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2493 GALA DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4839
Mailing Address - Country:US
Mailing Address - Phone:765-414-8227
Mailing Address - Fax:
Practice Address - Street 1:100 SAW MILL RD
Practice Address - Street 2:STE 3103
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5592
Practice Address - Country:US
Practice Address - Phone:765-414-8227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340039831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN070940KMedicare ID - Type Unspecified