Provider Demographics
NPI:1598091720
Name:JELLEN-THEISSEN, DINA LYNN (MA CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:DINA
Middle Name:LYNN
Last Name:JELLEN-THEISSEN
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14816 ENCLAVE LAKES DR
Mailing Address - Street 2:T2
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-8810
Mailing Address - Country:US
Mailing Address - Phone:561-901-4709
Mailing Address - Fax:
Practice Address - Street 1:14816 ENCLAVE LAKES DR
Practice Address - Street 2:T2
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8810
Practice Address - Country:US
Practice Address - Phone:561-901-4709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8760235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist