Provider Demographics
NPI:1487351177
Name:THEBO, LISA MARIE
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:THEBO
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 1:917 W NORTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4105
Mailing Address - Country:US
Mailing Address - Phone:231-728-3501
Mailing Address - Fax:231-246-1681
Practice Address - Street 1:645 S. MICHIGAN
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304
Practice Address - Country:US
Practice Address - Phone:231-728-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician