=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033821921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDRA MEEGAN THORNTON PCC-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2022
-----------------------------------------------------
Last Update Date | 12/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3461 WINDISCH AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45208-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-569-0939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 40TH AVE NE
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33703-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-503-1977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E.0501301-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------