Healthcare Provider Details

I. General information

NPI: 1053623439
Provider Name (Legal Business Name): SARA ELIABETH THORNTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA THORNTON LCSW

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 EAST AVE SUITE 6
WINFIELD MO
63389-3440
US

IV. Provider business mailing address

PO BOX 150 120 E AVE SUITE 6
WINFIELD MO
63389-0150
US

V. Phone/Fax

Practice location:
  • Phone: 314-497-9657
  • Fax:
Mailing address:
  • Phone: 314-497-9657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2009032268
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: