Provider Demographics
NPI:1285882092
Name:THEISEN, GEORGE LAWRENCE II (MFT)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:LAWRENCE
Last Name:THEISEN
Suffix:II
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3544
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-3544
Mailing Address - Country:US
Mailing Address - Phone:909-645-9601
Mailing Address - Fax:909-381-3501
Practice Address - Street 1:1911 COMMERCENTER E
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3454
Practice Address - Country:US
Practice Address - Phone:909-381-3579
Practice Address - Fax:909-381-3501
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 41555106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist