Provider Demographics
NPI:1245789791
Name:BRUCE THEOBALD, M.A., LPC
Entity type:Organization
Organization Name:BRUCE THEOBALD, M.A., LPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEOBALD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:615-752-7625
Mailing Address - Street 1:1107 BATTLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37069-6453
Mailing Address - Country:US
Mailing Address - Phone:615-752-7625
Mailing Address - Fax:
Practice Address - Street 1:1107 BATTLEWOOD ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37069-6453
Practice Address - Country:US
Practice Address - Phone:615-752-7625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2248101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty