Provider Demographics
NPI:1487077459
Name:THEBO, LYNN MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:LYNN
Middle Name:MARIE
Last Name:THEBO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 SOUTHWEST BLVD
Mailing Address - Street 2:STE. B
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904
Mailing Address - Country:US
Mailing Address - Phone:325-939-7641
Mailing Address - Fax:325-939-7641
Practice Address - Street 1:3109 SOUTHWEST BLVD.
Practice Address - Street 2:STE. B
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-939-7641
Practice Address - Fax:325-939-7641
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348231ZGGPOtherMEDICARE PTAN
TX348231ZGGPOtherMEDICARE PTAN