Provider Demographics
NPI:1598222630
Name:THORN, MICHELLE (EDD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:THORN
Suffix:
Gender:F
Credentials:EDD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 FERRIS ST
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-2114
Mailing Address - Country:US
Mailing Address - Phone:386-848-1647
Mailing Address - Fax:
Practice Address - Street 1:2851 FERRIS ST
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-2114
Practice Address - Country:US
Practice Address - Phone:386-848-1647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-33475103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst