Provider Demographics
NPI:1821260696
Name:THEISEN, AMYLYNN (MA, LPC, CAADC)
Entity Type:Individual
Prefix:
First Name:AMYLYNN
Middle Name:
Last Name:THEISEN
Suffix:
Gender:F
Credentials:MA, LPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N LANSING ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-1631
Mailing Address - Country:US
Mailing Address - Phone:989-944-2950
Mailing Address - Fax:989-317-3638
Practice Address - Street 1:1205 S MISSION ST
Practice Address - Street 2:STE 27
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3939
Practice Address - Country:US
Practice Address - Phone:989-944-2950
Practice Address - Fax:989-317-3638
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006678101YP2500X
MIC-01471101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)