Provider Demographics
NPI:1124326541
Name:THEISEN, ASHLEY LYNN
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNN
Last Name:THEISEN
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 1:140A AMAPOLA AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-3101
Mailing Address - Country:US
Mailing Address - Phone:650-995-4783
Mailing Address - Fax:
Practice Address - Street 1:931 SAN BRUNO AVE W
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3440
Practice Address - Country:US
Practice Address - Phone:415-681-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor