Provider Demographics
NPI:1003485046
Name:THORNTON, ANITA STAR ROGHANIAN (MFT-INTERN)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:STAR ROGHANIAN
Last Name:THORNTON
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 S DURANGO DR # 425
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-4455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7040 LAREDO ST STE K
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3044
Practice Address - Country:US
Practice Address - Phone:702-331-4874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1003485046106S00000X
NVMI4204106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1003485046Medicaid