Provider Demographics
NPI:1295910602
Name:THORNTON, THOMAS FLETCHER (LISW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:FLETCHER
Last Name:THORNTON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2062
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-2062
Mailing Address - Country:US
Mailing Address - Phone:505-429-1462
Mailing Address - Fax:
Practice Address - Street 1:1601-A ST. MICHAEL'S DR.
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1601
Practice Address - Country:US
Practice Address - Phone:509-429-1462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-15121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78558Medicaid