Healthcare Provider Details

I. General information

NPI: 1992386007
Provider Name (Legal Business Name): MCKENZIE THEISEN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 12/08/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5221 6TH STREET FRONTAGE RD E STE 100
SPRINGFIELD IL
62703-5745
US

IV. Provider business mailing address

1604 TORONTO RD APT 10
SPRINGFIELD IL
62712-3702
US

V. Phone/Fax

Practice location:
  • Phone: 712-305-5526
  • Fax:
Mailing address:
  • Phone: 712-305-5266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-70003
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-163887
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: