Healthcare Provider Details

I. General information

NPI: 1467445635
Provider Name (Legal Business Name): STEPHANNE CLINE THORNTON MAC, LCSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PLAYERS CLUB DR SUITE 301
CHARLESTON WV
25311-1639
US

IV. Provider business mailing address

1 PLAYERS CLUB DR SUITE 301
CHARLESTON WV
25311-1639
US

V. Phone/Fax

Practice location:
  • Phone: 706-254-9183
  • Fax:
Mailing address:
  • Phone: 706-254-9183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number106912
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number160
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3748
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00944073
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: