Provider Demographics
NPI:1053005272
Name:THORNTON, KARLEY MADISON
Entity type:Individual
Prefix:
First Name:KARLEY
Middle Name:MADISON
Last Name:THORNTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 EVANDERS WAY APT 307
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-1293
Mailing Address - Country:US
Mailing Address - Phone:910-305-5057
Mailing Address - Fax:
Practice Address - Street 1:280 EXECUTIVE PARK DRIVE SUITE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:207-237-4240
Practice Address - Fax:704-785-8304
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0194531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical