Healthcare Provider Details

I. General information

NPI: 1538340690
Provider Name (Legal Business Name): MARY LYNN THIENEMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8521 LAGRANGE RD
LOUISVILLE KY
40242-3800
US

IV. Provider business mailing address

POST OFFICE 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 TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0885
License Number StateKY

VIII. Authorized Official

Name: MRS. MARY LYNN THIENEMAN
Title or Position: OWNER
Credential: LCSW, LMFT
Phone: 502-644-5433