Provider Demographics
NPI:1407855414
Name:THELEN, KRISTINE A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:A
Last Name:THELEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:KRISTINE
Other - Middle Name:ANN
Other - Last Name:THELEN-EBERHART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:4209 CROSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628
Mailing Address - Country:US
Mailing Address - Phone:574-261-2488
Mailing Address - Fax:574-234-3565
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:SUITE 305
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1625
Practice Address - Country:US
Practice Address - Phone:574-234-3515
Practice Address - Fax:574-234-3565
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004344A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor