Provider Demographics
NPI:1124684451
Name:THEOBALT, KEANNA G
Entity type:Individual
Prefix:
First Name:KEANNA
Middle Name:G
Last Name:THEOBALT
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 1:9466 BLACK MOUNTAIN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4550
Mailing Address - Country:US
Mailing Address - Phone:858-689-2027
Mailing Address - Fax:
Practice Address - Street 1:43537 RIDGE PARK DR
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-3615
Practice Address - Country:US
Practice Address - Phone:858-689-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-18-70458106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician