Provider Demographics
NPI:1578038709
Name:THEADEMAN, ANNETTA ELIZABETH (CO60546132)
Entity Type:Individual
Prefix:
First Name:ANNETTA
Middle Name:ELIZABETH
Last Name:THEADEMAN
Suffix:
Gender:F
Credentials:CO60546132
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 W 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2506
Mailing Address - Country:US
Mailing Address - Phone:509-477-4652
Mailing Address - Fax:
Practice Address - Street 1:312 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2506
Practice Address - Country:US
Practice Address - Phone:509-477-4652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60546132101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor