Provider Demographics
NPI:1659958346
Name:THEOBALD, AZLEN OSKANIAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AZLEN
Middle Name:OSKANIAN
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 WINDING RD
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-1547
Mailing Address - Country:US
Mailing Address - Phone:610-389-4271
Mailing Address - Fax:
Practice Address - Street 1:2050 VOORHEES TOWN CTR
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1910
Practice Address - Country:US
Practice Address - Phone:856-345-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019234103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical