Provider Demographics
NPI:1821183443
Name:THORNTON, MATTIE L (BS)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:L
Last Name:THORNTON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WASHINGTON STREET
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:359 GRIDER STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:716-895-7715
Practice Address - Fax:716-893-1692
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000506354004OtherCOMMUNITY BLUE
NY00030241501OtherUNIVERA