Provider Demographics
NPI:1962576223
Name:THEOBALD, ELLEN MARIE (PHD)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:MARIE
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5307 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:951-683-2684
Mailing Address - Fax:951-683-2766
Practice Address - Street 1:5015 CANYON CREST DR
Practice Address - Street 2:SUITE 203
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507
Practice Address - Country:US
Practice Address - Phone:951-369-7416
Practice Address - Fax:951-787-9093
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00PL99530Medicare UPIN
00PL99530Medicare ID - Type Unspecified