Provider Demographics
NPI:1386317410
Name:THORNTON, MARY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18246 RAY ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7427
Mailing Address - Country:US
Mailing Address - Phone:734-642-8481
Mailing Address - Fax:
Practice Address - Street 1:1 PARKLANE BLVD STE 200E
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2400
Practice Address - Country:US
Practice Address - Phone:313-846-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7151013282235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist