Provider Demographics
NPI:1790894053
Name:WIARD, THEODORE JOHN (LPCC)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHN
Last Name:WIARD
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:07 CALLECITA
Mailing Address - Street 2:
Mailing Address - City:ARROYO HONDO
Mailing Address - State:NM
Mailing Address - Zip Code:87513
Mailing Address - Country:US
Mailing Address - Phone:505-690-0126
Mailing Address - Fax:575-586-1259
Practice Address - Street 1:07 CALLECITA
Practice Address - Street 2:
Practice Address - City:ARROYO HONDO
Practice Address - State:NM
Practice Address - Zip Code:87513
Practice Address - Country:US
Practice Address - Phone:505-690-0126
Practice Address - Fax:575-586-1259
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0109811101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral