Provider Demographics
NPI:1750540548
Name:THENO, LORI ROSE (MFT INTERN)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:ROSE
Last Name:THENO
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14360 SAINT ANDREWS DR STE 11
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4341
Mailing Address - Country:US
Mailing Address - Phone:760-245-4695
Mailing Address - Fax:760-245-5896
Practice Address - Street 1:14360 SAINT ANDREWS DR STE 11
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4341
Practice Address - Country:US
Practice Address - Phone:760-245-4695
Practice Address - Fax:760-245-5896
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55689106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist