Healthcare Provider Details

I. General information

NPI: 1972988764
Provider Name (Legal Business Name): KEISHA THORNTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 4TH AVE
CRESTVIEW FL
32536-2539
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 100183
GAINESVILLE FL
32610
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-7252
  • Fax:
Mailing address:
  • Phone: 352-392-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberISW8952
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW16905
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: