Provider Demographics
NPI:1225556863
Name:THORNTON, MARY EVELYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EVELYN
Last Name:THORNTON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 INDIAN RIVER AVE APT 1004
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796
Mailing Address - Country:US
Mailing Address - Phone:321-607-4020
Mailing Address - Fax:321-607-4020
Practice Address - Street 1:951 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796
Practice Address - Country:US
Practice Address - Phone:321-268-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist