Healthcare Provider Details

I. General information

NPI: 1659079127
Provider Name (Legal Business Name): SYDNEY C THEOBALD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 09/03/2026
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W MAIN ST
WATERTOWN NY
13601-1335
US

IV. Provider business mailing address

611 W MAIN ST
WATERTOWN NY
13601-1337
US

V. Phone/Fax

Practice location:
  • Phone: 888-585-2228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103761
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberP120209
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number119210
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: