Provider Demographics
NPI:1740225176
Name:GYDISH-THEOBALD, KIMBERLY MARIE (MED, LMHC,CAP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:GYDISH-THEOBALD
Suffix:
Gender:F
Credentials:MED, LMHC,CAP
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:GYDISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LMHC,CAP
Mailing Address - Street 1:1536 KINGSLEY AVE
Mailing Address - Street 2:SUITE 126
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4587
Mailing Address - Country:US
Mailing Address - Phone:904-264-8311
Mailing Address - Fax:904-264-8377
Practice Address - Street 1:1536 KINGSLEY AVE
Practice Address - Street 2:SUITE 126
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4587
Practice Address - Country:US
Practice Address - Phone:904-264-8311
Practice Address - Fax:904-264-8377
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7918101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health