Provider Demographics
NPI:1649599200
Name:THORNTON, DE'SHAUN
Entity Type:Individual
Prefix:MR
First Name:DE'SHAUN
Middle Name:
Last Name:THORNTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6304 N WILDEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-6436
Mailing Address - Country:US
Mailing Address - Phone:405-802-0702
Mailing Address - Fax:
Practice Address - Street 1:6304 N WILDEWOOD DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-6436
Practice Address - Country:US
Practice Address - Phone:405-802-0702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5489101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional