Provider Demographics
NPI:1285072900
Name:THORNBERRY, HEATHER MARTIN
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARTIN
Last Name:THORNBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 KINGS DR
Mailing Address - Street 2:
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035-7304
Mailing Address - Country:US
Mailing Address - Phone:859-653-2432
Mailing Address - Fax:
Practice Address - Street 1:34 KINGS DR
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035-7304
Practice Address - Country:US
Practice Address - Phone:598-130-7288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY290760101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN101YM0800XMedicare UPIN