Provider Demographics
NPI:1609920164
Name:THEIS, ROBERTA JO (MSE)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:JO
Last Name:THEIS
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:ROBERTA J THEIS
Mailing Address - Street 2:8010 60TH AVE. NORTH
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55428
Mailing Address - Country:US
Mailing Address - Phone:763-208-3784
Mailing Address - Fax:763-208-3784
Practice Address - Street 1:ROBERTA J THEIS
Practice Address - Street 2:8010 60TH AVE. NORTH
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55428
Practice Address - Country:US
Practice Address - Phone:763-208-3784
Practice Address - Fax:763-208-3784
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN086911041C0700X
MNLP1134103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN622252800Medicaid
MN40G40THOtherINDIVIDUAL BLUE CROSS BLU
MH40G39THOtherGROUP BLUE CROSS BLUE SHI