Provider Demographics
NPI:1538819412
Name:THORN, CHARLISE
Entity type:Individual
Prefix:
First Name:CHARLISE
Middle Name:
Last Name:THORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 SANTA FE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5153
Mailing Address - Country:US
Mailing Address - Phone:619-922-4553
Mailing Address - Fax:
Practice Address - Street 1:355 SANTA FE DR STE 200
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5153
Practice Address - Country:US
Practice Address - Phone:619-922-4553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPS894025489103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist