Provider Demographics
NPI:1598056707
Name:THEISEN, JUSTINE TAYLOR (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:TAYLOR
Last Name:THEISEN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MS
Other - First Name:JUSTINE
Other - Middle Name:LYNN
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-CLP
Mailing Address - Street 1:5811 BAMBOO DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-3758
Mailing Address - Country:US
Mailing Address - Phone:772-242-3187
Mailing Address - Fax:772-494-7262
Practice Address - Street 1:5811 BAMBOO DRIVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-3758
Practice Address - Country:US
Practice Address - Phone:772-242-3187
Practice Address - Fax:772-494-7262
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10918235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011847300Medicaid