Provider Demographics
NPI:1699807453
Name:THEIS, STEPHANIE ANNE (LCSW, MSW)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANNE
Last Name:THEIS
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-2712
Mailing Address - Country:US
Mailing Address - Phone:417-358-5653
Mailing Address - Fax:
Practice Address - Street 1:921 E 34TH ST STE A
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3933
Practice Address - Country:US
Practice Address - Phone:417-623-2292
Practice Address - Fax:417-623-3328
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040241501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO193119OtherBCBS OF MISSOURI