Provider Demographics
NPI:1598117475
Name:THEISEN, STEFANIE (MED BCBA)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:THEISEN
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43334 7 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2249
Mailing Address - Country:US
Mailing Address - Phone:844-247-7222
Mailing Address - Fax:
Practice Address - Street 1:43334 7 MILE RD STE 200
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-2249
Practice Address - Country:US
Practice Address - Phone:844-247-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM610777461858103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst