Provider Demographics
NPI:1790894053
Name:WIARD, THEODORE JOHN (LPCC)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHN
Last Name:WIARD
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 SIPAPU ST
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6498
Mailing Address - Country:US
Mailing Address - Phone:505-690-0126
Mailing Address - Fax:575-586-1259
Practice Address - Street 1:125 LA POSTA RD STE B15
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-7242
Practice Address - Country:US
Practice Address - Phone:505-690-0126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0109811101YP1600X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral