Basic Information
| Provider Information | |||||||||
| NPI: | 1700342995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THORNTON | ||||||||
| FirstName: | MIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 262 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142171539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142171539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 100119-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.