Provider Demographics
NPI:1770594566
Name:THORNTON, WILLSON S (PHD)
Entity type:Individual
Prefix:
First Name:WILLSON
Middle Name:S
Last Name:THORNTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:C-833
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2505
Mailing Address - Country:US
Mailing Address - Phone:972-566-6609
Mailing Address - Fax:972-566-6679
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:C-833
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-6609
Practice Address - Fax:972-566-6679
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23579103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23579OtherSTATE LICENSE
TX00R54MOtherMEDICARE
TXR94778Medicare UPIN