Provider Demographics
NPI:1932523107
Name:THEOBALD, FREDERICK LYNN (LPC)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:LYNN
Last Name:THEOBALD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10721 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-2753
Mailing Address - Country:US
Mailing Address - Phone:214-604-1042
Mailing Address - Fax:
Practice Address - Street 1:3402 OAK GROVE AVE
Practice Address - Street 2:SUITE NO. 305
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2353
Practice Address - Country:US
Practice Address - Phone:214-965-9104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-09
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68573101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor