Healthcare Provider Details

I. General information

NPI: 1700342995
Provider Name (Legal Business Name): MIA THORNTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 WOODWARD AVE
KENMORE NY
14217-1539
US

IV. Provider business mailing address

262 WOODWARD AVE
KENMORE NY
14217-1539
US

V. Phone/Fax

Practice location:
  • Phone: 716-842-0440
  • Fax: 716-842-4069
Mailing address:
  • Phone: 716-842-0440
  • Fax: 716-842-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number100119-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: