Provider Demographics
NPI:1487032207
Name:THEOBALD, CHRISTOPHER (LMFT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 W LANCASTER BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2303
Mailing Address - Country:US
Mailing Address - Phone:661-903-8822
Mailing Address - Fax:661-903-8860
Practice Address - Street 1:815 W LANCASTER BLVD STE 115
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2303
Practice Address - Country:US
Practice Address - Phone:661-903-8822
Practice Address - Fax:661-903-8860
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC5295101YM0800X
COLPC.0015944101YM0800X
CALMFT102727106H00000X
106H00000X
COMFT.0001733106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#95-2633765OtherMEDI-CAL