Provider Demographics
NPI:1043875628
Name:THORSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THORSON
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 1:1104 HEDGEROW DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3547
Mailing Address - Country:US
Mailing Address - Phone:847-275-4309
Mailing Address - Fax:
Practice Address - Street 1:1117 S MILWAUKEE AVE STE A12
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5268
Practice Address - Country:US
Practice Address - Phone:224-236-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional