Provider Demographics
NPI:1477892818
Name:THEOBALD, MONICA (LPC)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MCAFEE MEDICAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BEEBE
Mailing Address - State:AR
Mailing Address - Zip Code:72012-2217
Mailing Address - Country:US
Mailing Address - Phone:501-232-2600
Mailing Address - Fax:501-242-0820
Practice Address - Street 1:905 MCAFEE MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:BEEBE
Practice Address - State:AR
Practice Address - Zip Code:72012-2217
Practice Address - Country:US
Practice Address - Phone:501-232-2600
Practice Address - Fax:501-242-0820
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1607065101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5CB88OtherBCBS
AR195508795Medicaid