Provider Demographics
NPI:1063962173
Name:THORNTON, MIRANDA S (MS)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:S
Last Name:THORNTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 WATERTON CIR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-7200
Mailing Address - Country:US
Mailing Address - Phone:816-419-7865
Mailing Address - Fax:
Practice Address - Street 1:525 S CARROLL BLVD
Practice Address - Street 2:STE 204
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-7415
Practice Address - Country:US
Practice Address - Phone:940-594-4482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201848106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist