Healthcare Provider Details

I. General information

NPI: 1871188235
Provider Name (Legal Business Name): BETH GABRIELLE THORNTON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2021
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4753 NORTH BROADWAY ST
CHICAGO IL
60640
US

IV. Provider business mailing address

1431 OPUS PL STE 110
DOWNERS GROVE IL
60515-1164
US

V. Phone/Fax

Practice location:
  • Phone: 888-279-0002
  • Fax: 866-638-0302
Mailing address:
  • Phone: 888-279-0002
  • Fax: 833-638-0302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.024357
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1158128
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: