Provider Demographics
NPI:1881206316
Name:THEESFELD, MARY KATHERYN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERYN
Last Name:THEESFELD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAIN ST STE 304
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-1818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:191 WOODPORT RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-2607
Practice Address - Country:US
Practice Address - Phone:973-512-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC062939001041C0700X
NJ44SL06576500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker