Provider Demographics
NPI:1285395251
Name:THORNBERG, MARA ELIZABETH (LPC, LCPC)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:ELIZABETH
Last Name:THORNBERG
Suffix:
Gender:F
Credentials:LPC, LCPC
Other - Prefix:
Other - First Name:MARAH
Other - Middle Name:ELIZABETH
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 S MAIN ST STE 600
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5635
Mailing Address - Country:US
Mailing Address - Phone:512-661-2895
Mailing Address - Fax:
Practice Address - Street 1:1001 S MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5635
Practice Address - Country:US
Practice Address - Phone:512-661-2895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83681101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty