Healthcare Provider Details

I. General information

NPI: 1013826635
Provider Name (Legal Business Name): THERESA M THORNTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BOYKIN LAKES BLVD
PIKE ROAD AL
36064-3716
US

IV. Provider business mailing address

1101 RED VENTURES DR
FORT MILL SC
29707-5005
US

V. Phone/Fax

Practice location:
  • Phone: 334-233-9973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: