Provider Demographics
NPI:1912732058
Name:THORNTON, ISIAH
Entity type:Individual
Prefix:
First Name:ISIAH
Middle Name:
Last Name:THORNTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-2411
Mailing Address - Country:US
Mailing Address - Phone:860-478-6484
Mailing Address - Fax:
Practice Address - Street 1:49 LINDEN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-2411
Practice Address - Country:US
Practice Address - Phone:860-478-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician