Provider Demographics
NPI:1265855712
Name:LYNN M. THEBO, LCSW, PLLC
Entity Type:Organization
Organization Name:LYNN M. THEBO, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCSW
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:THEBO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:325-939-7641
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:
Practice Address - Street 1:3109 SOUTHWEST BLVD. STE. B
Practice Address - Street 2:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348226OtherMEDICARE PTAN
TX348226Medicare PIN