Provider Demographics
NPI:1699133975
Name:THORBOURNE, PATRICK GEORGE (MED ; BCBA)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:GEORGE
Last Name:THORBOURNE
Suffix:
Gender:M
Credentials:MED ; BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:317-516-6489
Mailing Address - Fax:
Practice Address - Street 1:3800 CAMP CREEK PKWY SW BLDG 1400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-6247
Practice Address - Country:US
Practice Address - Phone:770-999-9271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106E00000X, 106S00000X
GA1-19-38615103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1-19-38615OtherBCBA CERTIFICATE