Provider Demographics
NPI:1477827830
Name:THROCKMORTON, CLARA
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:THROCKMORTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 LAVISTA RD NE APT 2322
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3754
Mailing Address - Country:US
Mailing Address - Phone:734-678-1363
Mailing Address - Fax:
Practice Address - Street 1:1155 LAVISTA RD NE APT 2322
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3754
Practice Address - Country:US
Practice Address - Phone:734-678-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801092793104100000X
MI6801112468104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker