Provider Demographics
NPI:1700966504
Name:THORNBURGH, MYA (MSW, MPH)
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:
Last Name:THORNBURGH
Suffix:
Gender:F
Credentials:MSW, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 CRETE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3005
Mailing Address - Country:US
Mailing Address - Phone:504-568-0811
Mailing Address - Fax:
Practice Address - Street 1:1424 CRETE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-3005
Practice Address - Country:US
Practice Address - Phone:504-568-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8252284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital