Provider Demographics
NPI:1548320823
Name:THORN, TAMARA IDETTE (DMSC DSW LCSW, PA-C)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:IDETTE
Last Name:THORN
Suffix:
Gender:F
Credentials:DMSC DSW LCSW, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2687
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-2687
Mailing Address - Country:US
Mailing Address - Phone:704-898-7837
Mailing Address - Fax:912-244-9958
Practice Address - Street 1:3801 US HIGHWAY 17 STE 500
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-8877
Practice Address - Country:US
Practice Address - Phone:912-572-0358
Practice Address - Fax:912-244-9958
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YA0400X, 1041C0700X
NC101YA0400X, 1041C0700X
SC86541041C0700X
NCC0048441041C0700X
GA005697363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003179Medicaid
GA5697OtherPA LICENSE