Provider Demographics
NPI:1235223751
Name:THIENEMAN, MARY LYNN (LCSW, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:THIENEMAN
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22816
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-0816
Mailing Address - Country:US
Mailing Address - Phone:502-644-5433
Mailing Address - Fax:502-814-3745
Practice Address - Street 1:8521 LAGRANGE RD
Practice Address - Street 2:PHYSICIAN'S BLDG
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40242-3800
Practice Address - Country:US
Practice Address - Phone:502-644-5433
Practice Address - Fax:502-814-3745
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY08851041C0700X
KY0440106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY611367700Medicare UPIN
KY0644002Medicare ID - Type Unspecified