Provider Demographics
NPI:1790273795
Name:THEISS, JOSHUA B (LPC)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:B
Last Name:THEISS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 WYLIE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5405
Mailing Address - Country:US
Mailing Address - Phone:888-924-3786
Mailing Address - Fax:
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:618-397-0093
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009668101YA0400X, 101YM0800X
IL180009668101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health