Provider Demographics
NPI:1124447859
Name:THEIS, LINDA D (LL P)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:D
Last Name:THEIS
Suffix:
Gender:F
Credentials:LL P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 GONYER RD SW
Mailing Address - Street 2:
Mailing Address - City:FIFE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49633-8214
Mailing Address - Country:US
Mailing Address - Phone:231-715-9381
Mailing Address - Fax:
Practice Address - Street 1:6035 GONYER RD SW
Practice Address - Street 2:
Practice Address - City:FIFE LAKE
Practice Address - State:MI
Practice Address - Zip Code:49633-8214
Practice Address - Country:US
Practice Address - Phone:231-715-9381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015848103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical