Provider Demographics
NPI:1265722813
Name:THEISS, DIANA LYNN (PHD, LISW-S)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:LYNN
Last Name:THEISS
Suffix:
Gender:F
Credentials:PHD, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 MONROE ST STE A1
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2208
Mailing Address - Country:US
Mailing Address - Phone:419-276-3556
Mailing Address - Fax:
Practice Address - Street 1:5800 MONROE ST STE A1
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2208
Practice Address - Country:US
Practice Address - Phone:419-276-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-17
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0900183-SUPV104100000X
OHI-0900183-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0155198Medicaid