Provider Demographics
NPI:1700080801
Name:VONDRACEK, THEA (LMFT)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:VONDRACEK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 KOTCHS GROVE CT
Mailing Address - Street 2:
Mailing Address - City:BROWNS SUMMIT
Mailing Address - State:NC
Mailing Address - Zip Code:27214-9437
Mailing Address - Country:US
Mailing Address - Phone:336-295-3191
Mailing Address - Fax:
Practice Address - Street 1:1931 NEW GARDEN RD STE 212
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2556
Practice Address - Country:US
Practice Address - Phone:336-338-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1326106H00000X
NC6636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103607Medicaid