Provider Demographics
NPI:1720531908
Name:THORNTON, MARY GRACE (LPC)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 NW FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2752
Mailing Address - Country:US
Mailing Address - Phone:503-504-5886
Mailing Address - Fax:
Practice Address - Street 1:731 NW FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2752
Practice Address - Country:US
Practice Address - Phone:503-504-5886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4188101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health