Healthcare Provider Details

I. General information

NPI: 1306105440
Provider Name (Legal Business Name): MRS. BREANNA MARIE THORNTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA MARIE DELL

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MILITARY ST
PORT HURON MI
48060-5416
US

IV. Provider business mailing address

9075 CHATWELL CLUB DR
DAVISON MI
48423-3011
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-5168
  • Fax: 800-248-1568
Mailing address:
  • Phone: 810-941-7478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301019782
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: