Provider Demographics
NPI:1942383211
Name:THORNTON, TINA (RPT)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7302 YELLOWTAIL DR UNIT 202
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2447
Mailing Address - Country:US
Mailing Address - Phone:714-536-2557
Mailing Address - Fax:
Practice Address - Street 1:2760 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2755
Practice Address - Country:US
Practice Address - Phone:562-424-5198
Practice Address - Fax:562-427-1235
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT19953Medicare ID - Type Unspecified