Provider Demographics
NPI:1699423236
Name:THEIS, BRENT (MA, LPC-S)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:THEIS
Suffix:
Gender:M
Credentials:MA, LPC-S
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:
Other - Last Name:THEIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPC-S
Mailing Address - Street 1:701 E I30
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5504
Mailing Address - Country:US
Mailing Address - Phone:469-698-2250
Mailing Address - Fax:
Practice Address - Street 1:701 E I30
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-5504
Practice Address - Country:US
Practice Address - Phone:214-228-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60596101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional