Healthcare Provider Details

I. General information

NPI: 1992633101
Provider Name (Legal Business Name): MARIAH LYN THELEN AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 HUNT CLUB BLVD STE 208
GALLATIN TN
37066-6097
US

IV. Provider business mailing address

1531 HUNT CLUB BLVD STE 208
GALLATIN TN
37066-6097
US

V. Phone/Fax

Practice location:
  • Phone: 208-353-5594
  • Fax:
Mailing address:
  • Phone: 208-353-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2710
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: