Provider Demographics
NPI:1467445635
Name:THORNTON, STEPHANNE CLINE (MAC, LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANNE
Middle Name:CLINE
Last Name:THORNTON
Suffix:
Gender:F
Credentials:MAC, LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PLAYERS CLUB DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1639
Mailing Address - Country:US
Mailing Address - Phone:706-254-9183
Mailing Address - Fax:
Practice Address - Street 1:1 PLAYERS CLUB DR
Practice Address - Street 2:SUITE 301
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1639
Practice Address - Country:US
Practice Address - Phone:706-254-9183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1601041C0700X
GA37481041C0700X
WVDP009440731041C0700X
WV106912101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q41163Medicare UPIN
Q41163Medicare UPIN