Provider Demographics
NPI:1407357353
Name:THORNTON, MIRANDA ELLEN (LMSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELLEN
Last Name:THORNTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SUGAR MILL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2865
Mailing Address - Country:US
Mailing Address - Phone:770-771-6900
Mailing Address - Fax:
Practice Address - Street 1:500 SUGAR MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-2865
Practice Address - Country:US
Practice Address - Phone:801-963-4360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GAMSW011025104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician