Provider Demographics
NPI:1306105440
Name:THORNTON, BREANNA MARIE
Entity type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:MARIE
Last Name:THORNTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:MARIE
Other - Last Name:DELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1255 ASPEN DR
Mailing Address - Street 2:#3
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2428
Mailing Address - Country:US
Mailing Address - Phone:810-941-7478
Mailing Address - Fax:
Practice Address - Street 1:1001 MILITARY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5416
Practice Address - Country:US
Practice Address - Phone:810-985-5168
Practice Address - Fax:800-248-1568
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382230613OtherFIN #