Provider Demographics
NPI:1003321860
Name:THAXTON, DIAMOND M (LPMHC)
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:M
Last Name:THAXTON
Suffix:
Gender:F
Credentials:LPMHC
Other - Prefix:
Other - First Name:DIAMOND
Other - Middle Name:M
Other - Last Name:BRELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPMHC
Mailing Address - Street 1:135 RIDER AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1111
Mailing Address - Country:US
Mailing Address - Phone:315-414-8558
Mailing Address - Fax:
Practice Address - Street 1:7000 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1131
Practice Address - Country:US
Practice Address - Phone:315-446-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-02
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010830101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health