Healthcare Provider Details

I. General information

NPI: 1639426166
Provider Name (Legal Business Name): LINDA K THORNBERRY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDA K BECKER

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CENTRE DR
PETERSBURG IL
62675-9467
US

IV. Provider business mailing address

PO BOX 4566
SPRINGFIELD IL
62708-4566
US

V. Phone/Fax

Practice location:
  • Phone: 217-632-7761
  • Fax: 217-632-0312
Mailing address:
  • Phone: 800-577-5368
  • Fax: 217-757-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008613
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: