Provider Demographics
NPI:1255068391
Name:THEUS, ALICIA RENEE (DMFT)
Entity type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:RENEE
Last Name:THEUS
Suffix:
Gender:F
Credentials:DMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33311-2602
Mailing Address - Country:US
Mailing Address - Phone:954-651-2857
Mailing Address - Fax:
Practice Address - Street 1:12505 ORANGE DR STE 901
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4300
Practice Address - Country:US
Practice Address - Phone:954-651-2857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMH21400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health