Provider Demographics
NPI:1639504509
Name:THEISEN, LEAH MARIE (CFY-SLP MS)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:THEISEN
Suffix:
Gender:F
Credentials:CFY-SLP MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 HAPPY LN
Mailing Address - Street 2:APARTMENT # 3
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-3428
Mailing Address - Country:US
Mailing Address - Phone:262-751-3687
Mailing Address - Fax:
Practice Address - Street 1:3821 KOHLER MEMORIAL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3600
Practice Address - Country:US
Practice Address - Phone:920-208-9648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3886-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist