Provider Demographics
NPI:1992386007
Name:THEISEN, MCKENZIE (BCBA)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:THEISEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 TORONTO RD APT 10
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62712-3702
Mailing Address - Country:US
Mailing Address - Phone:712-305-5266
Mailing Address - Fax:
Practice Address - Street 1:5221 6TH STREET FRONTAGE RD E STE 100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5745
Practice Address - Country:US
Practice Address - Phone:712-305-5526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-163887106S00000X
1-23-70003103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician