Provider Demographics
NPI:1639426166
Name:THORNBERRY, LINDA K (LCSW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:K
Last Name:THORNBERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:K
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4566
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-4566
Mailing Address - Country:US
Mailing Address - Phone:800-577-5368
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:1 CENTRE DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IL
Practice Address - Zip Code:62675-9467
Practice Address - Country:US
Practice Address - Phone:217-632-7761
Practice Address - Fax:217-632-0312
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490086131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149008613OtherSTATE LICENSE