Provider Demographics
NPI:1558863381
Name:MATHIS-THORNTON, DIANA DAWN
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:DAWN
Last Name:MATHIS-THORNTON
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 1:533 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-2321
Mailing Address - Country:US
Mailing Address - Phone:214-356-0990
Mailing Address - Fax:972-218-8076
Practice Address - Street 1:533 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-2321
Practice Address - Country:US
Practice Address - Phone:214-356-0990
Practice Address - Fax:972-218-8076
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75644101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional