Provider Information for 1003321860
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DIAMOND M THAXTON LPMHC
Other Names:Former Name:DIAMOND M BRELAND LPMHCSex: Female
NPI: 1003321860
Last Updated: 2023-10-31
Certification Date: 2023-10-31
Certification Date: 2023-10-31
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1003321860 | ||||||||
| Enumeration Date | 2017-12-02 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 135 RIDER AVE SYRACUSE, NY 13207-1111 United States Phone: 315-414-8558 | Fax: | ||||||||
| Primary Practice Address | 7000 E GENESEE ST FAYETTEVILLE, NY 13066-1131 United States Phone: 315-446-4122 | Fax: | ||||||||
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