Provider Demographics
NPI:1851584528
Name:THEBERGE, DENISE AJALAT (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:AJALAT
Last Name:THEBERGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23030 LYONS AVE
Mailing Address - Street 2:# 202
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2752
Mailing Address - Country:US
Mailing Address - Phone:661-254-3577
Mailing Address - Fax:
Practice Address - Street 1:23030 LYONS AVE
Practice Address - Street 2:# 202
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2752
Practice Address - Country:US
Practice Address - Phone:661-254-3577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16031103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily