Provider Demographics
NPI:1366808974
Name:THEIS, MARY (MA, CSLG PSY LCPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THEIS
Suffix:
Gender:F
Credentials:MA, CSLG PSY LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9343 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1406
Mailing Address - Country:US
Mailing Address - Phone:847-677-7022
Mailing Address - Fax:
Practice Address - Street 1:9343 DRAKE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60203-1406
Practice Address - Country:US
Practice Address - Phone:847-677-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.004853101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional