Healthcare Provider Details

I. General information

NPI: 1174895403
Provider Name (Legal Business Name): ZACHARY JAMES THIENEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 DUPONT CIR SUITE 409
LOUISVILLE KY
40207-4812
US

IV. Provider business mailing address

4010 DUPONT CIR SUITE 409
LOUISVILLE KY
40207-4812
US

V. Phone/Fax

Practice location:
  • Phone: 502-409-4204
  • Fax:
Mailing address:
  • Phone: 502-409-4204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number170670
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: