Provider Demographics
NPI:1659079127
Name:THEOBALD, SYDNEY C (MSW)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:C
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1335
Practice Address - Country:US
Practice Address - Phone:888-585-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP120209104100000X
NY119210104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker