Healthcare Provider Details

I. General information

NPI: 1235223751
Provider Name (Legal Business Name): MARY LYNN THIENEMAN LCSW, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8521 LAGRANGE RD PHYSICIAN'S BLDG
LOUISVILLE KY
40242-3800
US

IV. Provider business mailing address

PO BOX 22816
LOUISVILLE KY
40252-0816
US

V. Phone/Fax

Practice location:
  • Phone: 502-644-5433
  • Fax: 502-814-3745
Mailing address:
  • Phone: 502-644-5433
  • Fax: 502-814-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0885
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0440
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: