Provider Demographics
NPI:1841565884
Name:THEISEN, ROBERTUS F
Entity Type:Individual
Prefix:
First Name:ROBERTUS
Middle Name:F
Last Name:THEISEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 COLCHESTER PKWY
Mailing Address - Street 2:SUITE 029D
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-3007
Mailing Address - Country:US
Mailing Address - Phone:802-847-2794
Mailing Address - Fax:
Practice Address - Street 1:790 COLCHESTER PARKWAY
Practice Address - Street 2:SUITE 029D
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3007
Practice Address - Country:US
Practice Address - Phone:802-847-2794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT48-0000560103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical