Provider Demographics
NPI:1104634948
Name:THIESS, EDEN KRISTINE
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:KRISTINE
Last Name:THIESS
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 1:1575 W WARM SPRINGS RD UNIT 2322
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-4303
Mailing Address - Country:US
Mailing Address - Phone:502-409-2574
Mailing Address - Fax:
Practice Address - Street 1:3320 N BUFFALO DR STE 207
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7411
Practice Address - Country:US
Practice Address - Phone:702-659-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI4451106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist