Basic Information
| Provider Information | |||||||||
| NPI: | 1699133975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THORBOURNE | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | MED ; BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175166489 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3800 CAMP CREEK PKWY SW BLDG 1400 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303316247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709999271 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2016 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | N | 106S00000X | N | 103K00000X | 1-19-38615 | GA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-19-38615 | 01 | GA | BCBA CERTIFICATE | OTHER |