Provider Demographics
NPI:1437336179
Name:THORN, TERRY LANE (MA EDS NATIONAL CERT)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LANE
Last Name:THORN
Suffix:
Gender:M
Credentials:MA EDS NATIONAL CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MORAN AVE
Mailing Address - Street 2:
Mailing Address - City:MULLENS
Mailing Address - State:WV
Mailing Address - Zip Code:25882
Mailing Address - Country:US
Mailing Address - Phone:304-294-5446
Mailing Address - Fax:
Practice Address - Street 1:RT 10
Practice Address - Street 2:WYOMING COUNTY SCHOOLS
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874
Practice Address - Country:US
Practice Address - Phone:304-732-6262
Practice Address - Fax:304-732-6214
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11100103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165555000Medicaid