Provider Demographics
NPI:1003228032
Name:DEBORAH M. THEVENIN, PH.D., LLC
Entity Type:Organization
Organization Name:DEBORAH M. THEVENIN, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:MORRISON
Authorized Official - Last Name:THEVENIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:305-495-7603
Mailing Address - Street 1:1500 BAY RD
Mailing Address - Street 2:UNIT 716 SOUTH
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-3252
Mailing Address - Country:US
Mailing Address - Phone:305-495-7603
Mailing Address - Fax:305-666-4311
Practice Address - Street 1:7685 SW 104TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-3161
Practice Address - Country:US
Practice Address - Phone:305-666-8000
Practice Address - Fax:305-666-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-26
Last Update Date:2014-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4442103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1376846295OtherNPI TYPE 1
FLFLPY4442OtherFLORIDA STATE PSYCHOLOGIST LICENSE